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OFFER OF OPTIONAL ADDITIONAL UNINSURED MOTORIST COVERAGE AND (Risk Placement Services, Inc.)

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M-3741g (12/2009)
M-3741g (12/2009) Page 1 of 3
OFFER OF OPTIONAL ADDITIONAL UNINSURED
MOTORIST COVERAGE AND OPTIONAL
UNDERINSURED MOTORIST COVERAGE
I. EXPLANATION OF COVERAGES
The State of South Carolina’s automobile insurance laws now allow any insurance company to refuse to
underwrite your automobile liability insurance coverage. That refusal may be based upon a number of reasons.
Automobile liability insurance coverage pays other motor vehicle drivers and their passengers whom you
damage for the damages which you cause and for which you are legally responsible. There are two types of
automobile liability insurance coverage: bodily injury and property damage. Bodily injury coverage is a
coverage which pays people upon whom your motor vehicle inflicts bodily injury. Property damage coverage is
a coverage which pays people for damages which your automobile causes to their motor vehicles or property.
Once any insurance company makes the business decision to underwrite your automobile liability insurance
coverage, then it must provide to you at least $25,000.00 of bodily injury coverage for each person whom you
may injure in any single accident and $50,000.00 of bodily injury coverage for two or more people whom you
may injure in any single accident. The insurance company must also provide to you at least $25,000.00 in
property damage coverage for each accident which you may cause. You may have seen these limits described
as $25,000/$50,000/$25,000 or 25/50/25. These limits are commonly known as minimum limits. If you
purchase automobile liability insurance, then, in order to drive your automobile upon the roads of this State, you
must have at least minimum limits.
There is no requirement under the laws of this State that an insurance company which underwrites your
minimum limits of $25,000/$50,000/$25,000 must also agree to underwrite higher than those minimum limits of
automobile liability insurance coverage for you. If your insurance company does agree to offer to you more than
the minimum limits, then you will be required to pay an increased automobile insurance premium for those
increased limits of protection.
In addition, under this State's insurance laws, once an insurance company agrees to underwrite your
automobile liability insurance coverage, you must be offered, at your option, two additional automobile insurance
coverages which will protect you in the event you are damaged in an automobile accident by an at-fault
automobile driver who either has no automobile insurance or whose automobile insurance liability limits are less
than the damages which you suffer in that accident. These coverages are legally termed additional uninsured
motorist coverage and underinsured motorist coverage. You may see them referred to within your automobile
insurance policy as UM and UIM. If you decide to purchase either of these two optional coverages, then you will
be required to pay an additional automobile insurance premium for each of these additional coverages.
Un
insured motorist coverage compensates you, or other persons insured under your automobile
insurance policy, for amounts which you may be legally entitled to collect as damages from an owner or operator
of an at-fault uninsured motor vehicle. An uninsured motor vehicle is a motor vehicle which either has no liability
insurance coverage or is operated by a hit-and-run driver. By law, your automobile insurance policy automatically
must provide uninsured motorist coverage of $25,000/$50,000/$25,000. All uninsured motorist coverages
provide for a $200 deductible for uninsured property damage claims.
You also have the right to buy additional uninsured motorist coverage, in various limits, up to the limits of
the liability coverage which you will carry under your automobile insurance policy. Some of the more commonly-
sold limits of additional uninsured motorist coverage, together with the additional premiums which you will be
charged, have been printed by your insurance company upon this form. If there are other limits in which you are
interested, but which are not shown upon this form, then fill in those limits in the blanks provided. If your
insurance company is allowed to market those limits within this State, then your insurance agent will fill in the
amounts of increased premium.
M-3741g (12/2009)
M-3741g (12/2009) Page 2 of 3
Underinsured motorist coverage compensates you, or other persons insured under your automobile
insurance policy, for amounts which you may be legally entitled to collect as damages from an owner or operator
of an at-fault underinsured motor vehicle. An underinsured motor vehicle is a motor vehicle which is covered by
some form of liability insurance, but that liability insurance coverage is not sufficient to fully compensate you for
your damages.
Your automobile insurance policy does not automatically provide any underinsured motorist coverage.
However, you have the right to buy underinsured motorist coverage in limits up to the limits of liability coverage
which you will carry under your automobile insurance policy. Some of the more commonly-sold limits of
underinsured motorist coverage, together with the additional premiums you will be charged, have been printed
by your insurance company upon this form. If there are other limits in which you are interested, but which are not
shown upon this form, then fill in those limits in the blanks provided. If your insurance company is allowed to
market those limits within this State, then your insurance agent will fill in the amounts of increased premium.
It is important that you understand that, if you reject either one of these coverages upon this form and if you
are involved in an automobile accident, then this form may be used by your insurance company as evidence
against you if it denies your claim for additional uninsured motorist coverage or underinsured motorist coverage.
If you do not complete this form and return it to your insurance company or to your insurance agent within 30
days from your receipt of this form, then the law requires that additional uninsured motorist coverage and
underinsured motorist coverage, in the same limits as the automobile liability insurance which you purchase,
must be automatically added on to your automobile insurance policy. You will be required to pay an additional
premium for each of these two coverages. If you do not pay that additional premium, then your automobile
insurance policy may be cancelled.
In the future, if you wish to increase or to decrease your limits either of additional uninsured motorist
coverage or of underinsured motorist coverage, you must then contact either your insurance agent or your
insurance company. You will not be presented with another copy of this form by your insurance agent or by your
insurance company upon renewal of your automobile liability insurance policy. You will not be presented with
another copy of this form by your insurance agent or by your current insurance company when you extend,
change, supersede, or replace your automobile liability insurance policy.
Please read this form carefully. Your insurance agent or your insurance company must answer any
questions which you may have. If you have any further questions, then you should contact the State of South
Carolina Department of Insurance. Its address and telephone number are:
Office of Consumer Services
State of South Carolina Department of Insurance
Capitol Center
1201 Main Street, Suite 1000
Post Office Box 100105
Columbia, South Carolina 29202-3105
(803) 737-6180
(800) 768-3467
E-mail Address: CnsmMail@doi.state.sc.us
M-3741g (12/2009)
M-3741g (12/2009) Page 3 of 3
II. OFFER OF ADDITIONAL UNINSURED MOTORIST COVERAGE
Limits of Coverage
Premium Cost
$25,000 / $50,000 / $25,000
Your Policy’s Liability Coverage Limits:
Ƒ I reject additional Uninsured Motorist Coverage
Ƒ I select additional Uninsured Motorist Coverage at the following limits:
III. OFFER OF UNDERINSURED MOTORIST COVERAGE
Limits of Coverage Premium Cost
$25,000 / $50,000 / $25,000
Your Policy’s Liability Coverage Limits:
Ƒ I reject additional Underinsured Motorist Coverage
Ƒ I select additional Underinsured Motorist Coverage
at the following limits:
IV. APPLICANT'S ACKNOWLEDGEMENT
By my signature, I acknowledge that I have read B or I have had read to me B the above explanations and
offers of additional uninsured motorist coverage and underinsured motorist coverage. I have indicated whether or
not I wish to purchase each coverage in the spaces provided. I understand that the above explanations of these
coverages are intended only to be brief descriptions of additional uninsured motorist coverage and underinsured
motorist coverage, and that payment of benefits under either of these coverages is subject both to the terms and
conditions of my automobile insurance policy and to the State of South Carolina's laws.
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OFFER OF OPTIONAL ADDITIONAL UNINSURED MOTORIST COVERAGE AND (Risk Placement Services, Inc.)

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Completed 23 November 2020

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