Fillable UNINSURED MOTORISTS COVERAGE SELECTION / REJECTION FORM NORTH (Risk Placement Services, Inc.)

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UNINSURED MOTORISTS COVERAGE SELECTION / REJECTION FORM NORTH (Risk Placement Services, Inc.)

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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 NC SUPP – Commercial
Page 1 of
3
(12-2014)
NORTH CAROLINA SUPPLEMENTAL APPLICATION
VEHICLES 26,001lbs and Over
INSURANCE COMPANY
MUST be completed if Auto Liability Coverage is requested
INDEMNITY COMPANY
1. Applicant Name
2. DBA, if any
3. NC Local Fire and Lightning Tax District
District County District ID#
SELECTION / REJECTION FORM
UNINSURED MOTORISTS COVERAGE
COMBINED UNINSURED / UNDERINSURED MOTORISTS COVERAGE
FOR “COMMERCIAL” VEHICLES
REJECTION OF UNINSURED OR COMBINED UNINSURED/UNDERINSURED MOTORISTS COVERAGE IS ONLY
PERMITTED FOR VEHICLES WITH A GROSS VEHICLE WEIGHT OF 26,001 AND OVER.
(For vehicle definitions,
please see G.S. 20-4.01(3d)).
Uninsured Motorists Coverage (UM) and Combined Uninsured/Underinsured Motorists Coverage (UM/UIM) coverage options are
available to me.
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 that result from an automobile accident with a hit-and-
run vehicle whose owner or operator cannot be identified.
Combined Uninsured/Underinsured 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 and/or underinsured motor vehicle
because of bodily injury or property damage caused by an automobile accident. Also included are damages due to bodily injury
that result from an automobile accident with a hit-and-run vehicle whose owner or operator cannot be identified.
I understand that:
1. The UM or UM/UIM limits applicable to any one vehicle covered under this policy may not be combined with or added to the
UM/UIM limits applicable to any other vehicle covered under the policy to determine the total amount of coverage provided.
2. UM and UM/UIM bodily injury limits up to $1,000,000 per person and $1,000,000 per accident are available.
3. You may purchase lesser limits, but not less than the minimum limit required by law,
4. UM property damage limits up to the highest policy property damage liability limits are available; however, the maximum
property damage limit allowed can only equal the highest limit of property damage coverage. Coverage for property damage is
applicable only to damages caused by uninsured motor vehicles.
5. My selection or rejection of coverage below will apply to any renewal, reinstatement, substitute, amended, altered, modified,
transfer or replacement policy with this company, or affiliated company, unless a named insured makes a written request to the
company to exercise a different option.
6. My selection or rejection of coverage below is valid and binding on all insureds and vehicles under the policy, unless a named
insured makes a written request to the company to exercise a different option.
Applicant’s Initials
THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 NC SUPP – Commercial
Page 2 of
3
(12-2014)
I AM REJECTING all offers of Uninsured Motorists Bodily Injury, Uninsured Motorists Property Damage, and Underinsured
Motorists Coverage. (Can only be rejected if all vehicles are over 26,001 GVW.)
Applicant’s Initials
SPLIT LIMITS
I select the following Split Limits (Per Person/Per Accident/Property Damage):
$30,000/60,000/25,0000
I understand that my policy will not include Underinsured Motorists Coverage if I select this limit.
$50,000/100,000/25,000
Applicant’s Initials
COMBINED SINGLE LIMITS
I select the following Combined Single Limits:
$85,000
$100,000
$125,000
$200,000
$300,000
$400,000
$500,000
$600,000
$750,000
$1,000,000
Applicant’s Initials
THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 NC SUPP – Commercial
Page 3 of
3
(12-2014)
AUTO MEDICAL PAYMENTS COVERAGE
We will pay reasonable expenses incurred for necessary medical and funeral services to or for an “insured” who sustains “bodily
injury” caused by “accident”. We will pay only those expenses incurred, for services rendered within three years from the date of
the “accident”.
$500
$1,000
$2,000
$5,000
I AM REJECTING all offers of Auto Medical Payments Coverage.
Applicant’s Initials
APPLICANT’S ACKNOWLEDGMENT
The undersigner(s) hereby acknowledge(s) they have read, or have had read to them and understand, the above explanations
and offers of Uninsured Motorist Bodily Injury and Property Damage Coverage, Combined Uninsured/Underinsured Motorist
Coverage and Auto Medical Payments Coverage. Selections have been made by checking the appropriate boxes in the Split
Limits section or the Combined Single Limits section and in the Auto Medical Payments section. The signature appearing
below is that of the named insured or authorization has been given to the signer of this Offer of Uninsured Motorist Bodily
Injury and Property Damage Coverage, Combined Uninsured/Underinsured Motorist Coverage and Auto Medical Payments
Coverage to select or reject coverage and limits on the behalf of the named insured.
YOUR SELECTION OR REJECTION OF UNINSURED MOTORIST BODILY INJURY AND PROPERTY DAMAGE COVERAGE
OR COMBINED UNINSURED/UNDERINSURED MOTORIST COVERAGE AND AUTO MEDICAL PAYMENTS COVERAGE IS
BINDING ON ALL PERSONS INSURED UNDER THIS POLICY.
Applicant /Named Insured: Date:
B
y
:
Title:
Signature of Agent of Insured: Date:
Address:
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UNINSURED MOTORISTS COVERAGE SELECTION REJECTION FORM NORTH (Risk Placement Services, Inc.)

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Completed 23 November 2020

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