COVERAGE SELECTIONS PAGE MASSACHUSETTS PERSONAL AUTOMOBILE Named .

Item 4. Coverages, Limits of Liability and Premiums (Continued)Insurance is provided only where a premium entry is shown for the coverage. The premium entry “Incl” or “Pkg”means the premium charge is included in the premium for another coverage or a package.AUTO 1Year MakeModelAUTO 2Year MakeModelAUTO 3Year MakeModelAUTO 4Year MakeModel XXX XXX XXX XXX5. Optional Bodily Injury To Others XX,XXX per person XX,XXX per accident XXX XXX XXX XXX6. Medical Payments XX,XXX per person XXX XXX XXX XXX7. CollisionActual Cash Value less XX,XXX deductible XXX XXX4. Damage To SomeoneElse’s Property(Compulsory Limit X,XXX) XX,XXX per accident[15]OPTIONAL INSURANCEParts 5, 6, 7, 8, 9, 10, 11, 12Stated Amount CoverageSee Endorsement E5LXXXX (XX-XX) XXX,XXX Stated Amountsubject to XXX deductibleWaiver Of DeductibleSee Endorsement E5OXXXX (XX-XX) XXX XXXInclInclInclIncl8. Limited Collision9. ComprehensiveActual Cash Value less XX,XXX deductibleActual Cash Value less XX,XXX deductibleStated Amount Coverage ComprehensiveSee Endorsement E5LXXXX (XX-XX) XX,XXX Stated Amountsubject to XX,XXX deductibleAgreed Amount Coverage ComprehensiveSee Endorsement E5BXXXX (XX-XX) XX,XXX Agreed Amountsubject to XX,XXX deductiblePL-50221 (05-15) (11-18)670/0XXXXX XXX XXX XXX XXXPage 2 of 6

Named InsuredPolicy PeriodXXXX XXXXXXXMMMMMM DD, YYYY to MMMMM DD, YYYYPolicy Number XXXXXXXXX XXX XIssued On Date MMMMM DD, YYYYItem 4. Coverages, Limits of Liability and Premiums (Continued)Insurance is provided only where a premium entry is shown for the coverage. The premium entry “Incl” or “Pkg”means the premium charge is included in the premium for another coverage or a package.AUTO 1Year MakeModel10. Substitute TransportationUp to XXX per day/ X,XXX maximumUp to XXX per day/ X,XXX maximum XXX11. Roadside AssistanceUp to XX miles per disablementUp to XXX miles per disablement XXX12. Bodily Injury Caused By AnUnderinsured Auto XX,XXX per person XX,XXX per accident[16]AUTO 2Year MakeModelAUTO 3Year MakeModelAUTO 4Year MakeModel XXX XXX XXX XXX XXXPkg XXX XXXOTHER COVERAGES/ENDORSEMENTSCustom Equipment – Increased LimitSee Endorsement E5EXXXX (XX-XX) XX,XXX per accident XXXLoan or Lease Gap CoverageSee Endorsement E5HXXXX (XX-XX)PkgNew Car Replacement CoverageSee Endorsement E5IXXXX (XX-XX)PkgPersonal Property CoverageSee Endorsement E5KXXXX (XX-XX) XX,XXX LimitPkgTrip Interruption CoverageSee Endorsement E5NXXXX (XX-XX)PkgOTHER PREMIUM*[17]Extended Non-Owned CoverageSee Endorsement E5GXXXX (XX-XX)PERSON1OTHERPREMIUM* XXXAccident ForgivenessPkgMinor Violation ForgivenessPkgDecreasing DeductibleSee Endorsement E5FXXXX (XX-XX)PkgTotal Loss Deductible WaiverSee Endorsement E5MXXXX (XX-XX)PkgPL-50221 (05-15) (11-18)670/0XXXXXPage 3 of 6

Item 4. Coverages, Limits of Liability and Premiums (Continued)Insurance is provided only where a premium entry is shown for the coverage. The premium entry “Incl” or “Pkg”means the premium charge is included in the premium for another coverage or a package.Package Premiums [18]Premier New Car Replacement XXXPremier Roadside Assistance XXX XXXPremier Responsible Driver PlanSubtotal for your auto(s): [19] X,XXX X,XXX X,XXX X,XXXSubtotal for Other Premium*: [20]Total Premium for this Policy:[22] X,XXX[21] XXXXThis is not a bill. You will be billed separately for this transaction.* Other Premium are charges for coverages and packages not specific to an auto. The Premier New Car Replacement Package consists of New Car Replacement Coverage and Loan or LeaseGap Coverage endorsements. The Premier Roadside Assistance Package consists of Roadside Assistance(Part 11) and Trip Interruption Coverage and Personal Property Coverage endorsements. The PremierResponsible Driver Plan consists of the Decreasing Deductible and Total Loss Deductible Waiverendorsements as well as the Accident Forgiveness and Minor Violation Forgiveness features. The ResponsibleDriver Plan consists of the Accident Forgiveness and Minor Violation Forgiveness features.[23]Item 5. Information Used To Rate Your Policy[24]DiscountsXXXXX DiscountXXXXX DiscountXXXXX DiscountYour Total Savings Reflected in Your Total Premium:‡[26]‡ XXXXTotal Savings above includes the Safe Driver Discount amount of XXX.SurchargesThe following surcharges are reflected in your total premium:IncidentXXXX[27][25]DateMM-DD-YYDriver and Auto DetailsDriversDate of Birth1. XXXXMM-DD-YY2. XXXXMM-DD-YYAutos1. [Year] [Make] [Model]2. [Year] [Make] [Model]3. [Year] [Make] [Model]4. [Year] [Make] [Model] XXXDriverXXXXLicense StatusDriver TypeDate First LicensedXXXXXXXXXXXXXXXXXXXXXXXXXXXUse of AutoMileageLocation of XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIf any of the information above is incorrect or has changed, please notify your Travelers representativeimmediately.PL-50221 (05-15) (11-18)670/0XXXXXPage 4 of 6

Named InsuredPolicy Period[28]XXXX XXXXXXXMMMMMM DD, YYYY to MMMMM DD, YYYYPolicy Number XXXXXXXXX XXX XIssued On Date MMMMM DD, YYYYItem 5. Information Used To Rate Your Policy (continued)Check carefully that all operators of your auto(s) are shown. Your failure to list a household member orany individual who customarily operates your auto may have very serious consequences.NOTICE: You must notify us of changes that have occurred prior to the renewal of this policy andduring the policy period. It is a crime to knowingly provide false or fraudulent information for thepurpose of defrauding an insurance company. If you or someone else on your behalf has knowinglygiven us false, deceptive, misleading or incomplete information and if such false, deceptive,misleading or incomplete information increases our risk of loss, we may refuse to pay claims underany or all of the Optional Insurance Parts and we may cancel your policy. Such information includesthe description and the place of garaging of the vehicles(s) to be insured, the names of all householdmembers and customary operators required to be listed and the answers given above for all listedoperators. We may also limit our payments under Part 3 and Part 4. Check to make certain that youhave correctly listed all operators and the completeness of their previous driving records. The MeritRating Board may verify the accuracy of the previous driving records of all listed operators.We will not pay for a collision or limited collision loss for an accident which occurs while your auto isbeing operated by a household member who is not listed as an operator on your policy. Payment iswithheld when the household member, if listed, would require the payment of additional premium onyour policy based on accurate information.PART 5 – OPTIONAL BODILY INJURY TO OTHERSThe limits shown for this Part are the total limits you have under Compulsory Bodily Injury to Others (Part 1)and this Part. This means that the Compulsory limits are included within the limits shown for this Part and arenot in addition to them.PART 12 - BODILY INJURY CAUSED BY AN UNDERINSURED AUTOThe limits shown for this Part are subject to adjustment. We will only pay for any unpaid damages up to thedifference between the total amount collected from the automobile bodily injury liability insurance covering theowner and operator of the underinsured auto and the limits shown for this Part.Item 6. Other Information[29]See Endorsement E5AXXXX (XX-XX)[30]XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXXSecured Lender / Lessor Information [31]Year Make ModelXXXXXXXXXXXVIN# XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXXLOAN #Forms That Are Part of This Policy [32]A01XXXX (XX-XX)Massachusetts Automobile Insurance PolicyE5AXXXX (XX-XX)Additional Insured – LessorE5BXXXX (XX-XX)Agreed Amount Coverage – ComprehensiveE5CXXXX (XX-XX)Amendment Of Policy ProvisionsE5EXXXX (XX-XX)Custom Equipment Coverage – Increased LimitE5FXXXX (XX-XX)Decreasing DeductibleE5GXXXX (XX-XX)Extended Non-Owned CoverageAdditional Insured – LessorYear Make ModelVIN# XXXXXXXXXXXXXXPL-50221 (05-15) (11-18)670/0XXXXXPage 5 of 6

Item 6. Other Information (continued)Forms That Are Part of This PolicyLoan Or Lease Gap CoverageE5HXXXX (XX-XX)New Car Replacement CoverageE5IXXXX (XX-XX)Personal Property CoverageE5KXXXX (XX-XX)Stated Amount CoverageE5LXXXX (XX-XX)E5MXXXX (XX-XX)Total Loss Deductible WaiverE5NXXXX (XX-XX)Trip Interruption CoverageE5OXXXX (XX-XX)Waiver Of Deductible[33]Issued on XX/XX/XXXXCountersignature:[34]FOR YOUR INFORMATIONFor information about how Travelers compensates independent agents and brokers, please visitwww.Travelers.com or call our toll free telephone number 1-866-904-8348. You may also request a written copyfrom Marketing at One Tower Square, 2GSA, Hartford, Connecticut 06183.PL-50221 (05-15) (11-18)670/0XXXXXPage 6 of 6

Filing Memo – Coverage Selections Page - PL-50221 - Variable Text DetailPL-50221 (05-15) is the Travelers’ proprietary Coverage Selections Page.As required in Bulletin 08-08, the variable text fields on the Coverage Selections Page are identified below alongwith the range of options and when they apply. The numbers in brackets listed below coincide with the numbersdisplayed on the Coverage Selections Page filing exhibit. On the exhibit we have identified the bracketednumbers in yellow for ease of reference. [ ]The items in [blue] identify the variable text areas and are in brackets [ ].[1] The Title: [COVERAGE SELECTIONS PAGE] prints on New Business, Rewrite or Policy Changetransactions.The Title: [COVERAGE SELECTIONS PAGE – RENEWAL] prints on a Renewal transaction.The Title: [COVERAGE SELECTIONS PAGE – REINSTATEMENT] prints on a reinstatementtransaction.[2] Under the heading: Named Insured – This policy is issued to: the following prints:[Title Prefix] [First Name] [Last Name][Street Address][City,] [State] [Zip Code][3] If the business is serviced by an Agent, the heading: [Your Agency’s Name and Address] printsand the following information is provided:[Agency Name][Street Address][City,] [State] [Zip Code][Agency Code XXXXXX][Agency Phone # X- XXX-XXX-XXXX]If the business is serviced by the company, the heading: [Your Service Center’s Address] printsand the following information is provided:[Travelers Service Center Name][Street Address][City,] [State] [Zip Code][Company Phone # X- XXX-XXX-XXXX][4] Under the heading: Your Insurer, the name and address of the underwriting company prints:[XXX XXXXXXXX XXXX XXXXXXXXX XXXXXXX][XXX XXXXX XXXXXX, XXXXXXXX, XX XXXXX][5] Next to the heading: Your Auto Policy Number, prints:Unique 9 digit number [XXXXXXXXX]; 3 digit form number [XXX]; 1 digit sequence number [X][6] Next to the heading: Your Account Number, prints, if applicable:Unique 9 character Billing Account Number [XXXXXXXXX]. If not applicable, the field is blank.[7] Next to the heading: For Policy Service, prints the applicable Agent or Company phone number: [XXXX-XXX-XXXX][8] Next to the heading: For Claim Service, prints the applicable Company Claim Service number: [XXXX-XXX-XXXX][9] The heading: [For Roadside Assistance] will only print if the policyholder has purchased Part 11Roadside Assistance. Next to the heading will then print the applicable phone number: [X XXXXXX-XXXX]

[10] Under the heading Item 2. Premium / Policy PeriodaFor all transactions, other than Policy Change Transactions, the following statements will printand include the applicable term premium and applicable policy period.Your Total Premium for the Policy Period is [ X,XXX.XX].The policy period is from [XXXX XX, XXXX] to [XXXX XX, XXXX] 12:01 A.M. STANDARD TIME atyour address shown in Item 1.b. For Policy Change Transactions:i. The following two statements will always print. The appropriate Change number and effective datewill be included in 01.01.This is change number [X], which is effective [XXXX, XX XXXX].02.* This Coverage Selections Page replaces all prior Automobile Policy Coverage SelectionsPages on the date on which this change is effective.ii. The following statement(s) will print as applicable:* Premium increase, print [Thischange increases the premium by XXX for the remainder of the policyperiod.]has been added.]has been added.]* Add Mortgagee, print [Mortgagee/Additional Insured has been added.]* Add Vehicle, print [Vehicle has been added.]* Add Endorsement, print [Endorsement has been added.]* Add F/R Information, print [Financial responsibility information has been added.]* Add Account Discount/Quantum Account Credit Residence, print [Multi‐Policy account discount has beenadded/Long‐term customer discount has been added.]* Delete Coverage, print [Coverage has been deleted.]* Delete Driver, print [Driver has been deleted.]* Delete Vehicle, print [Vehicle has been deleted.]* Delete Endorsement, print [Endorsement has been deleted.]* Delete F/R Information, print [Financial responsibility information has been deleted.]* Delete Account Discount/Quantum Account Credit Residence, print [Multi‐Policy account discount has beendeleted/Long‐term customer discount has been deleted.]* Change Named Insured's Address; print [Your address has been changed.]* Change Coverage, print [Coverage has been changed.]* Change Use Class, print [Use classification information has been changed.]* Add Coverage, print [Coverage* Add Driver, print [Driver* Change Driver Record Class, print [Drivingrecord information has changed]* Change Named Insured, print [Yourname has been changed.]* Change Vehicle, [Vehicle has been changed.]* Change Endorsement, [Endorsement has been changed.]* Change F/R Information, [Financial responsibility information has been changed.]* Change A/C/I Points, [Traffic incident information has been changed.][11]In Item 3. under the heading Your Autos, prints [Year] [Make ] and [Model] of each auto insured. Up to 4autos can appear per page.[12]Under the heading Identification Numbers will print each applicable auto’s [VIN number].Page 2 of 8

[13] a. [Item 4. Coverages, Limits of Liability and Premiums] (This heading always prints. If the section doesnot fit on the page the heading repeats at the top of thenext page and adds the word [(continued)]b. If there are more than 4 autos, a subheading will print [Auto(s) 1-4] Another subheading would then printto display the next group of autos for example [Auto(s) 5-X]c. Under the heading and to the right, as applicable, the reference to the specific auto i.e., [Auto X] etc., andits associated [Year], [Make] and [Model] will print.d. Below each Auto will display the premium applicable to the coverage. This premium will appear as:[ XXX], [Incl] or [Pkg].The premium entry of “Incl” means the premium charge is included in the premiumfor another coverage; the premium entry of “pkg” means the premium is included in a package premium.[14]For each Compulsory Coverage Part print as follows:1. Bodily Injury To Others(The current compulsory limits of 20,000/ 40,000 will always print)[ XX,XXX] per person[ XX,XXX] per accident2. Personal Injury Protection[ X,XXX] per person[ X,XXX] deductible(The current compulsory limit of [ 8,000] will always print)(A [ 0] deductible will print if no deductible is selected.The applicable deductible will print if a deductible is selected and willindicate whether the deductible applies to the named insured alone or tothe named insured and household members.)If the deductible is applicable to the named insured, it will print as follows:[ X,XXX] deductible [applies to you]If the deductible is applicable to the named insured and household members, it will print as follows:[ X,XXX] deductible [applies to you and household members]3. Bodily Injury Caused By AnUninsured Auto(Compulsory Limits [ XX,XXX/ XX,XXX]) (The current compulsory limits of [ 20,000/ 40,000] will always print)[ XXX,XXX] per person[ XXX,XXX] per accident(The actual limit selected will print)(The actual limit selected will print)4. Damage To SomeoneElse’s Property[15].(Compulsory Limit [ X,XXX](The current compulsory limit of [ 5,000] will always print)[ XXX,XXX] per accident(The actual limit selected will print)For each Optional Coverage Part always print the Coverage Part title. Print the applicable limit if theCoverage is selected as follows:5. Optional Bodily Injury To Others[ XXX,XXX] per person[ XXX,XXX] per accident(The actual limit selected will print)(The actual limit selected will print)6. Medical Payments[ XX,XXX] per person(The actual limit selected will print)7. Collision[Actual Cash Value less XX,XXX deductible](The narrative Actual Cash Value less the applicable deductiblewill print if ACV applies to any auto. If another auto(s) has ACV, but thedeductible differs, the narrative and deductible will print, as applicable.)[Stated Amount Coverage(The title & endorsement # will print, if Stated Amount CoverageSee Endorsement E5LMA00 (05-15) applies to any auto.) XXX,XXX Stated Amount(The stated amount and the applicable deductible will print.)subject to XX,XXX deductible](If another auto(s) has Stated Amount, its limit and deductible will print,as applicable.)Page 3 of 8

[Antique Auto EndorsementSee Endorsement E5DMA00 (05-15) XXX,XXX Stated Amountsubject to XX,XXX deductible](The title & endorsement # will print if Antique Auto Endorsementapplies to any auto)(The stated amount limit and deductible will print.)(If another auto(s) is an Antique Auto, its stated amount limit anddeductible will print, as applicable)[Waiver of DeductibleSee Endorsement E5OMA00 (05-15)](The title & endorsement # will print if Waiver Of Deductibleapplies to any auto)8. Limited Collision[Actual Cash Value less XX,XXX deductible](The narrative Actual Cash Value less the applicable deductiblewill print if ACV applies to any auto.) If another auto has ACV, but thedeductible differs, the narrative and deductible will print, as applicable.)[Stated Amount Coverage(The title & endorsement # will print, if Stated Amount CoverageSee Endorsement E5LM

Insurance is provided only where a premium entry is shown for the coverage. The premium entry "Incl" or "Pkg" means the premium charge is included in the premium for another coverage or a package. AUTO 1 AUTO 2 AUTO 3 AUTO 4 Year Make Year Make Year Make Year Make Model Model Model Model COVERAGES, Parts 1 - 12