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Insurance Motorist Coverage Election

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INSURANCE MOTORIST COVERAGE ELECTION

Applicant / Insured Information

Date of Birth:

Phone:

Email:

Policy and Vehicle Details

Policy Period From:

To:

Annual Premium: $

Coverage Election — Uninsured & Underinsured Motorist

The Insured elects the following with respect to Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverage. Select either Accept or Reject for each coverage type. Election becomes part of the policy and will apply for the policy period stated above unless a later written election is submitted and accepted by the insurer.

Uninsured Motorist (UM) Coverage

I Accept UM coverage with the following limits:

Bodily Injury Per Person: $

Bodily Injury Per Accident: $

Property Damage: $

I Reject UM coverage. I acknowledge that I have been offered UM coverage and that rejection is voluntary. By rejecting UM coverage I waive the insurer's obligation to provide UM benefits beyond any amounts otherwise payable under applicable law.

Underinsured Motorist (UIM) Coverage

I Accept UIM coverage with the following limits:

Bodily Injury Per Person: $

Bodily Injury Per Accident: $

Deductible (if applicable): $

I Reject UIM coverage. I understand that rejection is my express election and that I am declining benefits that otherwise would be available.

Optional Features

Stacking of UM/UIM limits (if allowed by policy and statute)    No stacking (single vehicle limit applies)

I elect to waive mandatory arbitration of UM/UIM disputes and retain the right to pursue claims in court where permitted by law.

Beneficiary / Payee for UM/UIM Benefits (Optional)

Name of preferred payee (if other than insured):

Exclusions and Limitations

UM and UIM coverages do not apply to claims arising from: (a) intentional acts by the insured; (b) vehicles used as public or livery conveyances unless specifically endorsed; (c) motor vehicles not covered under the policy unless required by statute; (d) claims arising while the insured is engaged in the commission of a felony; and (e) claims barred by applicable state law or public policy. Payment under UM/UIM may be reduced by amounts recovered from the tortfeasor and by any uninsured/underinsured benefits otherwise payable to the claimant.

Applicant Certification and Acknowledgment

I certify that the elections and rejections marked on this form represent my informed, voluntary choices. I acknowledge receipt of any required notices concerning the availability of UM and UIM coverages. I understand that elections may affect my premium and that changes to these elections may require written notice to and acceptance by the insurer. I declare under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge.

Printed Name:

Signature:

Title / Relationship (if signing on behalf of insured):

Date Signed:

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What the Insurance Motorist Coverage Election Is

An Insurance Motorist Coverage Election is a signed declaration by an insured or claimant that selects or declines specific motorist coverage options under an automobile insurance policy. The form records choices such as uninsured/underinsured motorist (UM/UIM) stacking, primary versus excess coverage, and elected limits where permitted by state law. Carriers use it to document informed consent, confirm which coverages apply to a claim, and set claim-handling expectations; a properly completed election can be relied on by claims examiners and regulators during disputes.

Why documenting an election matters for claims and compliance

Documenting an Insurance Motorist Coverage Election clarifies coverage boundaries, reduces disputes, and supports consistent claims handling. When executed electronically it meets the ESIGN Act (15 U.S.C. ch. 96) and UETA requirements where applicable, which helps preserve enforceability and a reliable audit trail.

Why documenting an election matters for claims and compliance

Who completes this election and why it matters

Typical users include claims adjusters, named insureds, brokers, and risk managers responsible for selecting or documenting motorist coverage elections.

  • Insured individuals: policyholders making stacking or UM/UIM coverage elections on their policies.
  • Claims adjusters: record the election during intake to determine benefits and subrogation implications.
  • Agents and brokers: advise clients and document elected options at issuance or renewal.

Ensuring the correct signer and timing reduces processing delays, supports regulatory compliance, and helps preserve the insured’s intended coverage position.

Common signers and their responsibilities

Claims Adjuster

A claims adjuster typically completes or requests the election during claim intake to document coverage decisions. The adjuster confirms policy numbers, records elected options, notes any witness or notarization needs, and routes the completed form to underwriting and claims records.

Policyholder

The named insured or authorized representative must sign to confirm their election. Accurate entry of the insured’s legal name, policy number, and chosen limits is essential because mismatches can delay processing or create enforceability questions in later disputes.

Step-by-step: completing and submitting the election

Follow these steps to complete the Insurance Motorist Coverage Election accurately, in the correct order, and with required supporting information.

  • 01
    Gather Documents: Collect ID, policy declarations, and claim number.
  • 02
    Complete Fields: Enter names, dates, policy numbers, and elected options.
  • 03
    Review & Initial: Verify all values and initial any edited lines.
  • 04
    Sign & Submit: Sign, date, and send to insurer or upload to portal.

Recommended digital workflow settings for e-submission

Configure your digital workflow so the election captures required fields, authenticates signers, enforces validation, and routes final copies to claims and underwriting.

Field Configuration
Signature Type Electronic signature with detailed audit trail and timestamp.
Signer Authentication Email plus optional SMS or knowledge-based authentication (KBA).
Field Validation Rules Enforce MM/DD/YYYY for dates and numeric formats for limits.
Routing Auto-send final PDF to claims file and underwriting mailbox.

How submissions typically flow to the insurer

Election delivery varies by insurer: use portal upload, secure email, mailed originals, or an authenticated eSign link depending on the carrier’s preferences.

  • Upload: Upload completed election to insurer portal or agent inbox.
  • Email: Email a PDF to the insurer’s claims address with claim number.
  • Mail: Mail original signed election to the insurer’s claims department when required.
  • eSign Link: Send a secure signing link and capture the platform audit trail.

Technical and compliance requirements for digital submission

Confirm file formats, authentication methods, and audit-trail capture before e-submitting an election to an insurer.

  • Supported Formats: PDF and DOCX
  • Authentication: Email + optional SMS/KBA
  • Audit Trail: Timestamps, IP, action log

Timing considerations and typical deadlines

Complete the election at policy issuance or during claim intake; specific insurer or state rules may impose additional timing requirements.

At Policy Issuance:

Provide election when policy is issued or materially changed.

Upon Claims Intake:

Complete election during initial claim reporting to determine benefits.

Upon Payer Request:

Furnish election within the insurer-specified timeframe when requested.

Before Settlement:

Finalize election prior to benefit determination or settlement discussions.

State Deadlines May Apply:

Some states set notice or election periods; check local rules.

Key milestones from issuance to final determination

Track these sequential milestones to avoid processing bottlenecks and ensure each review stage is complete before the next begins.

01

Policy Issuance

Document election at or shortly after policy effective date.

02

Initial Claim Intake

Obtain or confirm election when claim is first reported.

03

Underwriting/Review

Underwriting confirms election aligns with policy language and endorsements.

04

Final Determination

Claims team uses the election to determine benefits or settlement.

Common mistakes to avoid when preparing the election

  • Using informal language or vague descriptions for coverage options, which creates ambiguity and invites disputes over what was elected.
  • Entering mismatched names or incorrect policy numbers, which can delay verification and may cause the insurer to challenge the election’s validity.
  • Failing to capture the signer’s role or authentication method, leaving attribution gaps in the audit trail that undermine enforceability.
  • Skipping required fields, dates, or initials on edited lines, which can permit a carrier to argue incomplete consent or lack of informed election.

Risks and potential consequences of an incorrect election

Coverage Denial: Election errors can lead to denied claims.
Claims Delay: Processing delays from verification and rework.
Regulatory Action: Potential regulator inquiry or sanction.
Contractual Dispute: Disagreements over elected limits or stacking.
Financial Exposure: Incorrect elections may increase out-of-pocket costs.
Evidence Weakness: Incomplete audit trails weaken enforceability.

Security and compliance considerations

Encryption: TLS 1.2/1.3; AES-256 at rest
HIPAA: BAA required for PHI
ESIGN/UETA: Legal e-signature framework
Audit Trail: Timestamps, IP, signer actions
21 CFR Part 11: Available for regulated workflows
SOC 2 / ISO: SOC 2 Type II and ISO 27001

Real-world examples of how elections are used

Two concise scenarios show how proper elections reduce disputes and speed claim resolution.

Regional Insurer

A mid-size carrier standardized elections during policy issuance to reduce ambiguity about stacking.

  • Implementation required structured fields and signer attribution.
  • After standardization, internal dispute referrals fell and adjusters could resolve coverage questions faster because elections were consistently documented and accessible.

Claims Unit Pilot

A claims unit implemented e-submission of elections via secure links to reduce paper handling.

  • The pilot used email+SMS authentication for high-value claims.
  • The unit observed fewer follow-up verification requests and a clearer audit trail for contested UM/UIM determinations, aiding timely settlements.

Typical eSignature vendor comparison for processing elections

Pricing and capabilities vary by vendor and plan; signNow is shown first for comparison and plan features differ by tier and billing model.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about completing and using the election

Answers to common questions about signature method, validity, corrections, and evidence preservation for Insurance Motorist Coverage Elections.


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