Fillable VIRGINIA SUPPLEMENTAL APPLICATION in conjunction with Form A-101 (Risk Placement Services, Inc.)

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VIRGINIA SUPPLEMENTAL APPLICATION in conjunction with Form A-101 (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 VA SUPP Page 1 of 1 (Rev. 9-2005)
VIRGINIA SUPPLEMENTAL APPLICATION
INSURANCE COMPANY
MUST be completed
in conjunction with Form A-101 VA
only if Auto Liability Coverage is requested
INDEMNITY COMPANY
1. Applicant Name
2. DBA, if any
NEW POLICY CANCELLATION NOTICE
READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED, MAY
BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING
WHICH IT IS IN EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
VIRGINIA FRAUD WARNING
WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
UNINSURED MOTORIST SELECTION / REJECTION
UNINSURED MOTORIST COVERAGE (UM) - In accordance with the laws of Virginia your policy will contain UM coverage with
limits equal to the liability limits of your policy. You will be charged for these limits. If you desire you may reject UM limits equal to
liability limits. Your selection or rejection of coverage is binding on all persons insured under this policy. Please indicate your
selection below:
Accept UM limits equal to liability limits
Reject UM limits equal to liability limits and request UM limits of 25/50/20
Reject UM limits equal to liability limits and request limits of
Date Application Completed Signature of Agent of Applicant
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VIRGINIA SUPPLEMENTAL APPLICATION in conjunction with Form A-101 (Risk Placement Services, Inc.)

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Completed 23 November 2020

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