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SOUTH CAROLINA SUPPLEMENTAL APPLICATION MUST be completed if (Risk Placement Services, Inc.)

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HIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 SC SUPP Page 1 of 4 (6-2014)
SOUTH CAROLINA SUPPLEMENTAL APPLICATION
INSURANCE COMPANY
MUST be completed if Auto Liability Coverage is requested
1. Applicant Name
2. DBA, if any
NOTICE: THE INSURER CAN CANCEL THIS POLICY FOR WHICH YOU ARE APPLYING WITHOUT CAUSE DURING THE FIRST 90
DAYS. THAT IS THE INSURER’S CHOICE. AFTER THE FIRST 90 DAYS, THE INSURER CAN ONLY CANCEL THIS POLICY FOR
REASONS STATED IN THE POLICY.
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 of bodily injury coverage for each person whom you may injure in any single accident
and $50,000 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 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 the 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.
Uninsured 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 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.
THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 SC SUPP Page 2 of 4 (6-2014)
Underinsured motorist coverage compensates you, or other persons insured under your automobile insurance policy, for
amounts which you legally may be 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 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.
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 canceled.
In the future, if you wish to increase or to decrease your limits either of additional uninsured motorist coverage or of
underinsured motorist coverage, then 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 the renewal of your
automobile liability insurance policy. You will not be presented with another copy of the 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 numbers are:
Office of Consumer Services, State of South Carolina Department of Insurance
Post Office Box 100105
Columbia, South Carolina 29202
(803) 737-6180 (800) 768-3467
E-mail Address: consumers@doi.sc.gov
THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 SC SUPP Page 3 of 4 (6-2014)
II. OFFER OF ADDITIONAL UNINSURED MOTORIST COVERAGE
Limits
of
Coverage Premium
25/50/25 51.00
25/100/25 69.00
25/300/25 94.00
50/100/25 74.00
100/300/50 99.00
100/300/100 179.00
Limits
of
Coverage Premium
75,000 CSL 88.00
80,000 CSL 92.00
85,000 CSL 96.00
100,000 CSL 109.00
200,000 CSL 179.00
250,000 CSL 210.00
300,000 CSL 240.00
350,000 CSL 264.00
500,000 CSL 334.00
600,000 CSL 364.00
750,000 CSL 394.00
900,000 CSL 424.00
1,000,000 CSL 440.00
* Minimum limits of 25,000/50,000/25,000 for uninsured motorist coverage are required to be purchased.
Do you wish to purchase additional uninsured motorist coverage? Yes
No
If your answer is "yes", then specify the limits which you desire. These limits cannot exceed your automobile insurance liability
limits.
Limits Desired Bodily Injury Property Damage -OR- Combined Single Limits
,000 / ,000 ,000 ,000
Sign here to confirm your selection: _______________________________________________X
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THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 SC SUPP Page 4 of 4 (6-2014)
III. OFFER OF UNDERINSURED MOTORIST COVERAGE
Limits
of
Coverage Premium
25/50/25 51.00
25/100/25 69.00
25/300/25 94.00
50/100/25 74.00
100/300/50 99.00
100/300/100 179.00
Limits
of
Coverage Premium
75,000 CSL 88.00
80,000 CSL 92.00
85,000 CSL 96.00
100,000 CSL 109.00
200,000 CSL 179.00
250,000 CSL 210.00
300,000 CSL 240.00
350,000 CSL 264.00
500,000 CSL 334.00
600,000 CSL 364.00
750,000 CSL 394.00
900,000 CSL 424.00
1,000,000 CSL 440.00
Do you wish to purchase underinsured motorist coverage? Yes
No
If your answer is “yes”, then specify the limits which you desire. These limits cannot exceed your uninsured motorist limits selected
above.
Limits Desired Bodily Injury Property Damage -OR- Combined Single Limits
,000 / ,000 ,000 ,000
Sign here to confirm your selection: _____________________________________________X
For an additional premium charge optional limits for UM and/or UIM are available up to the limits of your liability coverage. Our
agent can quote premium prices for you.
IV. APPLICANT’S ACKNOWLEDGEMENT
By my signature, I hereby acknowledge that I have read, or have had read to me, 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 further understand that the above explanations of these coverages are intended only to be brief
descriptions of coverages, and that payment of benefits under any 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. This signed form is to be returned to the insurer.
Your Signature:
X
Your Address:
Type or Print Your Name:
Today’s Date:
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SOUTH CAROLINA SUPPLEMENTAL APPLICATION MUST be completed if (Risk Placement Services, Inc.)

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Completed 23 November 2020

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