Insurance UIM Form

Insurance UIM Form

Applicant / Insured Information

Client Name:

Policy Coverage Details

Policy Type:

Coverage Election

Select the insured's election regarding Underinsured Motorist (UIM) coverage. By checking "Accept", the insured elects UIM coverage as described in the policy. By checking "Reject", the insured declines UIM coverage and acknowledges the waiver statement below.

If rejecting or limiting coverage, initial here to acknowledge you have been informed of your right to UIM coverage and the effect of your election:

Persons and Vehicles Covered

Exclusions and Limitations

The following are common exclusions to UIM coverage and will apply unless otherwise required by law: punitive damages, intentional acts by the insured, vehicles used as public or livery conveyances for hire unless specifically endorsed, use of a vehicle for commercial haulage not scheduled on the policy, and losses arising from war, nuclear incident or insurrection. This list is illustrative, not exhaustive.

I acknowledge that I have read and understand the exclusions described above and the policy's subrogation provisions requiring cooperation with the insurer's recovery efforts against responsible third parties.

Beneficiary Designation for UIM Payments

Designate one or more beneficiaries to receive proceeds of any UIM payment due under this policy in the event of the insured's death. If no beneficiary is designated, payment will be made in accordance with policy terms and law.

Claim Information (If Applicable)

If submitting this form as a claim for UIM benefits, complete the following or attach a signed statement describing the loss and supporting documentation as required by the policy.

Documentation Checklist

Please indicate which documents are attached or will be provided to support this claim or election.

Declaration and Certification

I declare under penalty of perjury that the information provided on this form is true, correct and complete to the best of my knowledge. I understand that providing false or misleading information may constitute insurance fraud and may result in denial of coverage or termination of the policy. I authorize the insurer to obtain and disclose information reasonably necessary to investigate this election or claim, including medical records, police reports and other relevant documentation, and I agree to cooperate with reasonable requests for information and assistance. I acknowledge that acceptance or rejection of Underinsured Motorist coverage will be effective only upon endorsement to the policy as required by law and policy terms.

I further acknowledge that by signing below I understand the insurer's right of subrogation against responsible third parties and agree to reasonably cooperate with subrogation efforts, including assignment of recovered proceeds to the insurer in accordance with the policy.

Sign Now