Fillable SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION TENNESSEE PROTECTION AGAINST UNINSURED (Risk Placement Services, Inc.)

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SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION TENNESSEE PROTECTION AGAINST UNINSURED (Risk Placement Services, Inc.)

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Name
N-3537 (6/10)
Address
Page 1 of 2
SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION
PROTECTION AGAINST UNINSURED MOTORISTS
Uninsured Motorists coverage provides protection against damages for bodily injury which an insured is legally entitled
to recover from the owner or driver of a motor vehicle: 1) for which there is no insurance; 2) is a hit-and-run vehicle; 3)
whose insurer becomes insolvent or denies coverage; or 4) for which the sum of the limits of liability available to the
insured is less than, or reduced by payments to persons other than the insured to an amount less than, the applicable
limits of Uninsured Motorists coverage provided to the insured under your policy. Your Uninsured Motorists coverage
may also provide protection for property damage to either the insured vehicle or property owned by an insured while in
the insured vehicle.
Refer to your policy for the prevailing coverage provisions.
In accordance with the laws of Tennessee, your automobile liability or motor vehicle policy shall
automatically
include
Uninsured Motorists coverage for damages for bodily injury at the same limits as the Bodily Injury Liability policy limits,
unless you reject said coverage or select lower limits, below.
If you purchase Uninsured Motorists coverage for bodily injury, we are required to provide you with the opportunity to
purchase Uninsured Motorists coverage for property damage in amount not to exceed the Property Damage Liability
policy limits. Property damage is subject to a $200 deductible.
Your selection of limits for Uninsured Motorists coverage may not be less than the Minimum Financial Responsibility
Limits of $25,000 each person/$50,000 each accident for bodily injury or $15,000 each accident for property damage; or
$60,000 each accident combined single limit (CSL).
Please indicate how you wish your coverage to apply by checking the proper box and signing the space below.
I wish to
reject
Uninsured Motorists coverage for bodily injury and for property damage.
I wish to
reject
Uninsured
Motorists property damage coverage, but I wish to
select
Uninsured Motorists coverage
for bodily injury at Minimum Financial Responsibility Limits of $25,000 each person/$50,000 each accident; or
$50,000 each accident single limit. The Uninsured Motorists coverage limits will be either split (each person/each
accident) or single limit, consistent with the Bodily Injury Liability limits on your policy.
I wish to
reject
Uninsured Motorists property damage coverage, but I wish to
select
Uninsured Motorists coverage
for bodily injury at limits equal to the Bodily Injury Liability limits.
TENNESSEE
(To be completed and signed by Named Insured
)
N-3537 (6/10)
Page 2 of 2
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 premium, 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
I wish to
reject
Uninsured Motorists property damage coverage, but I wish to
select
Uninsured Motorists coverage
for bodily injury in the following limit:
(Specify)
I wish to
select
Uninsured Motorists coverage for bodily injury
and
property damage at Minimum Financial
Responsibility Limits of $25,000 each person/$50,000 each accident for bodily injury and $15,000 each accident for
property damage; or $60,000
each accident combined single limit (CSL).
The Uninsured Motorists coverage limits
will be either split (each person/each accident) or combined single limit (CSL), consistent with the Liability limits on
your policy.
I wish to
select
Uninsured Motorists coverage for bodily injury
and
property damage at limits equal to the Liability
limits.
I wish to
select
both Uninsured Motorists coverage for bodily injury
and
property damage in the following limit:
(Specify)
$100,000 each accident
$250,000 each accident
$300,000 each accident
$350,000 each accident
$500,000 each accident
$750,000 each accident
$1,000,000 each accident
$
$65,000 each accident (CSL)
$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)
$
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SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION TENNESSEE PROTECTION AGAINST UNINSURED (Risk Placement Services, Inc.)

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Completed 30 July 2020

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