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Signature of Insured
EFFECTIVE DATE NAIC CODECARRIERPOLICY NUMBER
NAMED INSURED(S)
AGENCY
AGENCY CUSTOMER ID:
ARKANSAS AUTO SUPPLEMENT
I understand that the coverage selection indicated here will apply to all future policy renewals,
continuations and changes unless I notify you otherwise in writing.
Coverage is generally described here. Only the policy provides a complete description of the
coverages and their limitations.
Under the Arkansas Insurance Laws (Section 23-89-209), amended, you, the insured named in
the policy, are permitted to reject Underinsured Motorists Coverage. Underinsured Motorists
Coverage enables the insured or his/her legal representative to recover from the insurer the
amount of damages for bodily injury or death to which the insured is legally entitled from the
owner or operator of another vehicle. Coverage shall not be reduced by the other party's
insurance coverage except to the extent that the injured party would receive compensation in
excess of his/her damages.
UNINSURED/UNDERINSURED MOTORISTS COVERAGE SELECTION
Signature of Insured
In accordance with the Arkansas Insurance Laws (Section 23-89-403, 23-89-404 and 23-89-209),
amended, the undersigned insured (and each of them):
Agrees that both Uninsured and Underinsured Motorists Coverages afforded in the policy
are hereby deleted.
Agrees that the property damage only portion of the Uninsured Motorists Coverage afforded
in the policy is hereby deleted.
Agrees that only Underinsured Motorists Coverage afforded in the policy is hereby deleted.
Signature of Applicant
I acknowledge that I have been offered Uninsured and Underinsured Motorists coverage limits
equal to the minimum limits required by law. Minimum limits are $25,000 per person, $50,000 per
accident for Bodily Injury, $25,000 per accident for Property Damage. I have also been offered
limits equal to the liability limits of my policy. If I have rejected higher limits, my signature is
provided here:
The Arkansas Insurance Laws (Section 23-89-403 and 23-89-404), amended, permits you, the
insured named in the policy, to reject the Uninsured Motorists Coverage in its entirety or to reject
the property damage only portion of the Uninsured Motorists Coverage. Uninsured Motorists
Coverage provides insurance for the protection of persons insured thereunder who are legally
entitled to recover damages from owners or operators of uninsured motor vehicles because of
bodily injury, sickness or disease, including death, resulting therefrom, and for property damage to
the insured vehicle for losses in excess of two hundred dollars ($200).
ACORD 61 AR (2010/04) © 1994-2010 ACORD CORPORATION. All rights reserved.
