Fillable NORTH CAROLINA UNINSURED/UNDERINSURED MOTORIST COVERAGE SELECTION FORM North (Risk Placement Services, Inc.)

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NORTH CAROLINA UNINSURED/UNDERINSURED MOTORIST COVERAGE SELECTION FORM North (Risk Placement Services, Inc.)

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M-3937b (09/2009)
M-3937b (09/2009)
NORTH CAROLINA UNINSURED/UNDERINSURED MOTORIST COVERAGE
SELECTION FORM
North Carolina Statute § 20-279.21 permits any insured named in the policy to choose Uninsured Motorist
Coverage and Underinsured Motorist Coverage. You may choose limits as low as minimum financial
responsibility or any other limit we offer up to a maximum of $1,000,000 Bodily Injury per person,
$1,000,000 Bodily Injury per accident, and $1,000,000 Property Damage per accident. You may also
choose a $1,000,000 Combined Single Limit for Bodily Injury and Property Damage.
To be certain that your policy is issued correctly, please review your choice of the options available, then
sign, date, and return this form as acknowledgement of your choice. The options you requested are
reproduced below. These options determined your policy premium, but you may change them. Changing
these options may result in changes to your premium.
The undersigned insured chooses the following:
Uninsured Motorist Coverage at the following limits:
Bodily Injury per person:
B
odily Injury per accident:
Property Damage per accident: ; or
Bodily Injury Combined Single Limit:
Underinsured Motorist Coverage at the following limits:
Bodily Injury per person:
B
odily Injury per accident:
Property Damage per accident: ; or
Bodily Injury Combined Single Limit:
Note: Underinsured Mo
torist Coverage is not available when purchasing liability coverage at
minimum financial responsibility limits.
Signature of Named Insured or Legal Representative Date
UNTIL YOU ADVISE US OTHERWISE IN WRITING, YOUR CHOICE INDICATED ABOVE WILL
CONTINUE REGARDLESS OF ANY CHANGE TO YOUR AUTO COVERAGE—INCLUDING THE
ADDITION OF COVERED AUTOS OR AN INCREASE IN LIABILITY LIMITS—AND WILL BE CARRIED
FORWARD TO ANY CONTINUATION, RENEWAL, REINSTATEMENT OR REPLACEMENT POLICY.
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NORTH CAROLINA UNINSUREDUNDERINSURED MOTORIST COVERAGE SELECTION FORM North (Risk Placement Services, Inc.)

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Completed 23 November 2020

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