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SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION GEORGIA (Risk Placement Services, Inc.)

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Name
N-3512 (6/10)
Address
Page 1 of 4
SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION
GEORGIA
(To be completed and signed by Named Insured
)
IMPORTANT NOTICE
GEORGIA UNINSURED MOTORISTS COVERAGE
PLEASE READ THIS NOTICE CAREFULLY.
If you have chosen to accept Uninsured Motorists Coverage from your automobile insurance company, and have any
questions after reading this statement regarding Uninsured Motorists Coverage or the amount of coverage you have
selected, your agent or company representative will be able to assist you.
Our records show that your policy contains Uninsured Motorists (UM) Coverage. Uninsured Motorists Coverage
provides insurance protection to an insured for compensatory damages which the insured is legally entitled to recover
from the owner or operator of an uninsured motor vehicle because of bodily injury or property damage caused by an
automobile accident. Also included are damages due to bodily injury or property damage that result from an automobile
accident with a hit-and-run vehicle whose owner or operator cannot be identified. This document includes general
descriptions of coverage. However, no coverage is provided by this document. You should read your policy for
information on the coverage you are provided.
Georgia law, in general, requires that automobile liability policies include Uninsured Motorists Coverage Added On To
At-Fault Liability limits (Added-On) unless you reject this coverage in writing. Uninsured Motorists Added-On Coverage
provides insurance protection, in general, with respect to an insured's covered losses that are in addition to the limit of
liability under any applicable bonds or policies.
However, for a reduced premium, you may reject Uninsured Motorists Added-On Coverage and select Uninsured
Motorists Coverage - Reduced By At-Fault Liability Limits (Reduced by Limits). Uninsured Motorists Reduced by Limits
Coverage provides insurance protection, in general, wherein the amount of coverage is reduced by all sums paid by or
on behalf of anyone who is legally responsible.
The purpose of this notice is informational. This notice does not change or replace the wording in your policy.
Your signature below, as applicable to this Important Notice, is required only at the inception of
your new policy with the Company.
Signature of Named Insured
Date
click to sign
signature
click to edit
N-3512 (6/10)
Page 2 of 4
Name
Address
UNINSURED MOTORISTS (ADDED-ON) COVERAGE
Uninsured Motorists Coverage provides protection against damages for bodily injury or property damage which the
insured is legally entitled to recover from the owner or driver of a motor vehicle which: has no insurance coverage; is a
hit and run vehicle; whose insurer is or becomes insolvent; or which is an underinsured motor vehicle. An underinsured
motor vehicle is a vehicle whose limits of liability are less than the sum of the limits of your Uninsured Motorists
Coverage
and
the limits of any other Uninsured Motorists Coverage applicable to the insured. Refer to your policy for
the prevailing coverage provisions.
In accordance with the laws of Georgia, your automobile liability or motor vehicle liability policy shall
automatically
include Uninsured Motorists Added-On Coverage
equal
to the Bodily Injury and Property Damage Liability Limits of your
policy. You may, however, elect lower limits of Uninsured Motorists Added-On Coverage, but not less than the minimum
Financial Responsibility Limits of $25,000 each person/$50,000 each accident bodily injury and $25,000 each accident
property damage; or $75,000 each accident
Combined Single Limits (CSL).
You also have the option to reject
Uninsured Motorists Added-On Coverage entirely as indicated below.
Please indicate your Uninsured Motorists Added-On Coverage selection, or rejection, as follows:
I wish to
select
the Uninsured Motorists Added-On Coverage at Minimum Financial Responsibility Limits. The
Uninsured Motorists Added-On Coverage limits will be either split (each person/each accident) or a Combined
Single Limit (CSL), consistent with the Bodily Injury Liability Limits on your policy.
I wish to
select
limits less than the policy Bodily Injury and Property Damage Liability limits (Specify limit.)
$100,000 each accident (CSL)
$250,000 each accident (CSL)
$300,000 each accident (CSL)
$350,000 each accident (CSL)
$500,000 each accident (CSL)
$750,000 each accident (CSL)
$1,000,000 each accident (CSL)
$
I wish to
select
limits equal to the policy Bodily Injury and Property Damage Liability limits.
I
reject
Uninsured Motorists Added-On Coverage.
GEORGIA
(To be completed and signed by Named Insured
)
SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION
N-3512 (6/10)
Page 3 of 4
UNINSURED MOTORISTS (REDUCED BY LIMITS) COVERAGE
Uninsured Motorists Coverage provides protection against damages for bodily injury or property damage which the
insured is legally entitled to recover from the owner or driver of a motor vehicle which: has no insurance coverage; is a
hit and run vehicle; whose insurer is or becomes insolvent; or which is an underinsured motor vehicle. An underinsured
motor vehicle is a vehicle whose limits of liability are less than the sum of the limits of your Uninsured Motorists
Coverage
and
the limits of any other Uninsured Motorists Coverage applicable to the insured. Refer to your policy for
the prevailing coverage provisions.
In accordance with the laws of Georgia, IF YOU HAVE REJECTED Uninsured Motorists Added-On Coverage your
automobile liability or motor vehicle liability policy shall
automatically
include Uninsured Motorists Reduced By Limits
Coverage
equal
to the Bodily Injury and Property Damage Liability Limits of your policy. You may, however, elect lower
limits of Uninsured Motorists Reduced By Limits Coverage, but not less than the Minimum Financial Responsibility Limits
of $25,000 each person/$50,000 each accident bodily injury and $25,000 each accident property damage; or $75,000
each accident Combined Single Limits (CSL). You also have the option to reject Uninsured Motorists Reduced By Limits
Coverage entirely as indicated below.
Please indicate your Uninsured Motorists Reduced by Limits Coverage selection, or rejection, as follows:
I wish to
select
the Uninsured Motorists Reduced By Limits Coverage at Minimum Financial Responsibility limits.
The Uninsured Motorists Reduced By Limits Coverage limits will be either split (each person/each accident) or a
Combined Single Limit (CSL), consistent with the Bodily Injury Liability Limits on your policy.
I wish to
select
limits less than the policy Bodily Injury and Property Damage Liability limits (Specify limit.)
$100,000 each accident (CSL)
$250,000 each accident (CSL)
$300,000 each accident (CSL)
$350,000 each accident (CSL)
$500,000 each accident (CSL)
$750,000 each accident (CSL)
$1,000,000 each accident (CSL)
$
I wish to
select
limits equal to the policy Bodily Injury and Property Damage Liability limits.
I
reject
Uninsured Motorists Reduced By Limits Coverage.
N-3512 (6/10)
Page 4 of 4
I
understand
that
my
coverage
election
shall
apply
on
the
policy
or
policies
in
effect
at
the
time
this
form
is
executed
and all future renewal policies until I notify
the Company
IN WRITING of any changes.
My
signature
below,
and/or
payment
of
any
premiums
evidences
my
actual
knowledge
and
understanding
of
the
availability of these benefits and limits as well as the benefits and limits I have selected, rejected or accepted by default.
Signature of Named Insured
Date
You may select Uninsured Motorists Added-On Coverage or Uninsured Motorists Reduced By Limits Coverage with or
without a deductible. Please indicate your choice below:
No deductible.
$500 deductible each accident OR if Split Limits
$250 bodily injury each accident
$250 property damage each accident
$1,000 deductible each accident OR if Split Limits
$500 bodily injury each accident
$500 property damage each accident
$2,000 deductible each accident OR if Split Limits
$1,000 bodily injury each accident
$1,000 property damage each accident
IF YOU HAVE ELECTED TO PURCHASE A LARGE DEDUCTIBLE RATING PLAN, THE DEDUCTIBLE RATING PLAN
AMOUNT SHOWN ON THE DEDUCTIBLE ENDORSEMENT IN YOUR POLICY SHALL APPLY AS YOUR
UNINSURED MOTORISTS COVERAGE DEDUCTIBLE.
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SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION GEORGIA (Risk Placement Services, Inc.)

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Completed 23 November 2020

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