M-5682 (02/2012)
M-5682 (02/2012)
UNINSURED MOTORIST COVERAGE SELECTION / REJECTION
Uninsured Motorist Coverage provides protection for damages incurred as a result of an accident with an uninsured motor
vehicle. You have the right to purchase Uninsured 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 Uninsured Motorist Coverage, and you have the
right to reject this coverage. You also have the option to purchase Uninsured Motorist Coverage with limits of coverage less
than that of your Bodily Injury Liability Coverage limit. Uninsured Motorist Coverage is an optional coverage; however, we are
required to include it in your policy unless you take steps to reject it.
NOTE: 75 Pa.C.S.A. § 1731(b.1) forbids rejection of uninsured motorist coverage for "Common Carriers by Motor Vehicle" as
defined in 66 Pa.C.S.A.§ 102.
INDICATE YOUR CHOICE BY EITHER COMPLETING THE REJECTION OF UNINSURED MOTORIST COVERAGE
SECTION (OPTION ONE) OR BY COMPLETING THE SELECTION OF UNINSURED MOTORIST COVERAGE AND
STACKING OPTIONS SECTION (OPTION TWO)
OPTION ONE
REJECTION OF UNINSURED MOTORIST PROTECTION
By signing this waiver I am rejecting uninsured motorist coverage under this policy, for myself and all relatives residing in
my household. Uninsured 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 any insurance to pay for 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 UNINSURED MOTORIST PROTECTION AND STACKING OPTIONS
A.
Selection of UM Coverage:
I do wish to purchase Uninsured Motorist Coverage at $
per
person, $
per accident split limits of liability or $ per accident single limit of liability.
(Your UM 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 Uninsured Motorist Coverage, and you are an individual, your 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 Uninsured 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 Uninsured
Motorist Coverage. There is an additional premium for this
coverage.
Unless you specifically reject stacking of Uninsured Motorist Coverage (or the Named Insured is not an individual),
your Uninsured Motorist Coverage stacks by default.
Ƒ Rejection of Stacking:
I do not wish to purchase stacking of Uninsured Motorist Coverage or the Named Insured is
not an individual.
UNINSURED COVERAGE LIMITS
B
y signing this waiver, I am rejecting stacked limits of uninsured 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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