# Chubb Global Casualty

Please indicate your choice by initialing next to the appropriate item and signing below.

Choose one Split Limits Bodily Injury option AND one Property Damage limit option OR one Combined Single Limit option from the following:

## Split Limits Bodily

| (Initials) | Injury | Premium | (Initials) | Property Damage | Premium |
|------------|--------|---------|------------|-----------------|---------|
| $          | 50,000/100,000 $ | $        | $          | 10,000 $         | $       |
|            | 100,000/200,000 |           |            | 15,000           |         |
|            | 100,000/300,000 |           |            | 20,000           |         |
|            | 250,000/500,000 |           |            | 25,000           |         |
|            | 300,000/300,000 |           |            | 50,000           |         |
|            | 500,000/1,000,000 |           |            | 100,000          |         |
|            | 1,000,000/1,000,000 |           |            | 150,000          |         |
|            | (Other) |           |            | 200,000          |         |
|            |          |           |            | 250,000          |         |
|            |          |           |            | 500,000          |         |
|            |          |           |            | 750,000          |         |
|            |          |           |            | 1,000,000        |         |

## Combined Single Limit

| (Initials) | Combined Single Limit | Premium |
|------------|-----------------------|---------|
| $          | 110,000               | $       |
|            | 125,000               |         |
|            | 150,000               |         |
|            | 200,000               |         |
|            | 250,000               |         |
|            | 300,000               |         |
|            | 350,000               |         |
|            | 400,000               |         |
|            | 500,000               |         |
|            | 510,000               |         |
|            | 600,000               |         |
|            | 750,000               |         |
|            | 1,000,000             |         |

IL U 078 Ed. 7/2/2020  
Page 17 of 55  
INTERNA_05212023_William Overby  
04/28/2023