<INSERT COMPANY FORM NUMBER> Ed. 7/2/2023 Page 3 of 6
Section A: Your PIP Medical Choices and the Risks and Benefits of Each
Option 1: Unlimited Coverage
This option provides the most coverage. It will pay for all allowable expenses for your care, recovery, and rehabilitation
if you are injured in an auto accident.
Risks The premiums for this option are higher than premiums for other options.
Benefits
will cover costs that may not be covered by health insurance, such as rehabilitation and
attendant care.
This choice will significantly limit the risk that you will have out-of-pocket costs for your care.
Option 2: Limited Coverage of $500,000 per person per accident or
Option 3: Limited Coverage of $250,000 per person per accident
If you choose one of these limits, this amount is the most your auto insurance company will pay per person per accident
for an injured person’s expenses under PIP medical coverage.
NOTE: If you choose Option 2 or Option 3, your insurance company must offer excess attendant care coverage, which
you may purchase for an additional premium. Check with your agent or company for additional information.
Risks
Limited PIP medical coverages may not be enough to cover your medical expenses. If your PIP
medical limit is reached, you may need to rely on other health coverage, which may not cover all
medical, rehabilitation or attendant care costs. If you do not have other health coverage, you may be
personally responsible for paying these expenses.
Benefits
Lower coverage limits have less expensive premiums than plans with higher or unlimited
coverage.
Up to the limit chosen, PIP medical will cover the cost of products and services that may not be
covered by health insurance, such as rehabilitation and attendant care.
Option 4: Limited Coverage of $250,000 per person per accident with some or all persons excluded
You may select this option if both of the following are true:
• The applicant or named insured has qualified health coverage that is not Medicare; AND
• Each spouse or resident relative excluded from PIP medical has qualified health coverage.
Anyone who is excluded will have no PIP medical coverage. A person listed as excluded in Section B of this form will
only be excluded if proof of qualified health coverage is provided for that person. Any person who is not excluded will
be limited to $250,000 in PIP medical coverage and will be charged the appropriate premium for this coverage.
NOTE: If you choose this option, your insurance company must offer excess attendant care, which you may purchase
for an additional premium. This coverage is only available to those who are not excluded from PIP medical coverage.
Check with your agent or company for additional information.
Risks ANYONE YOU EXCLUDE WILL NOT HAVE PIP MEDICAL COVERAGE.
In addition:
• Persons relying on qualified health coverage to pay for auto accident injuries should be
aware that, unlike auto insurance, health insurance stops paying when the policy ends or is
canceled.
• If any excluded person loses qualified health coverage, you must notify your insurer within
30 days of loss of coverage.
• Within 30 days of losing qualified health coverage, if an excluded person is injured in an
auto accident, coverage will be provided by the Michigan Assigned Claims Plan up to
$2,000,000 if they have no other qualified health coverage or PIP medical coverage.
• A person who has not obtained qualified health coverage or PIP medical coverage within
30 days of the loss of qualified health coverage will not be entitled to any PIP medical
benefits.
Benefits
You will pay a reduced premium because you will not be charged a premium for PIP medical
coverage for anyone who is excluded.