M-5681 (02/2012)
M-5681 (02/2012)
UNDERINSURED MOTORIST COVERAGE SELECTION / REJECTION
Underinsured Motorist Coverage provides protection for damages incurred which exceed the limit of liability carried by the driver
of a vehicle who injures you in an automobile accident. You have the right to purchase Underinsured Motorist Coverage in an
amount equal to the amount of Bodily Injury Liability Coverage provided in your policy. The law does not require you to
purchase Underinsured Motorist Coverage, and you have the right to reject this coverage. You also have the option to purchase
Underinsured Motorist Coverage with limits of coverage less than that of your Bodily Injury Liability Coverage limit.
Underinsured Motorist Coverage is an optional coverage; however, we are required to include it in your policy unless you take
steps to reject it.
INDICATE YOUR CHOICE BY EITHER COMPLETING THE REJECTION OF
UNDERINSURED MOTORIST COVERAGE SECTION (OPTION ONE) OR BY COMPLETING THE SELECTION
OF UNDERINSURED MOTORIST COVERAGE AND STACKING OPTIONS SECTION (OPTION TWO)
OPTION ONE
REJECTION OF UNDERINSURED MOTORIST PROTECTION
By signing this waiver I am rejecting underinsured motorist coverage under this policy, for myself and all relatives
residing in my household. Underinsured coverage protects me and relatives living in my household for losses and
damages suffered if injury is caused by the negligence of a driver who does not have enough insurance to pay for all
losses and damages. I knowingly and voluntarily reject this coverage.
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Signature of First Named Insured Date Signed
OPTION TWO
SELECTION OF UNDERINSURED MOTORIST PROTECTION AND STACKING OPTIONS
A.
Selection of UIM Coverage:
I do wish to purchase Underinsured Motorist Coverage at $
per
person, $
per accident split limits of liability or $ per accident single limit of
liability. (Your UIM limits selection cannot be greater than your policy Bodily Injury Liability Coverage Limit.)
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Signature of First Named Insured Date Signed
B. Stacking Options: If you have chosen to purchase Underinsured Motorist Coverage, and you are an individual,
yo
ur next option is to determine if you want to stack the limits of your policy. Stacking means you can claim a total of
the amounts of Underinsured Motorist Coverage assigned to each vehicle in your policy. If you reject stacked limits,
each vehicle insured under the policy will have its own limit of Underinsured Motorist Coverage. There is an
additional premium for this coverage. Please check one box below to indicate your choice.
Unless you specifically reject stacking of Underinsured Motorist Coverage (or the Named Insured is not an
individual), your Underinsured Motorist Coverage stacks by default.
Ƒ Rejection of Stacking:
I do not with to purchase stacking of Uninsured Motorist Coverage or the Named
Insured is not an individual.
UNDERINSURED COVERAGE LIMITS
By
signing this waiver, I am rejecting stacked limits of underinsured motorist coverage under the policy for
myself and members of my household under which the limits of coverage available would be the sum of limits
for each motor vehicle insured under the policy. Instead the limits of coverage that I am purchasing shall be
reduced to the limits stated in the policy. I knowingly and voluntarily reject the stacked limits of coverage. I
understand that my premiums will be reduced if I reject this coverage.
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Signature of First Named Insured Date Signed
THE OPTIONS SELECTED SHALL CONTINUE IN FORCE AND EFFECT UNTIL REPLACEMENT WRITTEN NOTICE
IS RECEIVED BY THE COMPANY, OR ITS REPRESENTATIVE.
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