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Insurance UM and UIM Option Form

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INSURANCE UM AND UIM OPTION FORM

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Number:    Policy Type:

Policy Period: From to

UM / UIM Coverage Election

The undersigned insured elects the Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverage options for the policy identified above. Selections below apply to all insured vehicles and insured persons under the policy unless a specific vehicle or named insured is identified in writing.

Accept UM and UIM coverage as selected below.
Reject UM and UIM coverage entirely and waive rights to UM and UIM recovery.

If accepting, choose limits (select one):
$25,000 per person / $50,000 per accident    $50,000 per person / $100,000 per accident
$100,000 per person / $300,000 per accident    Limits equal to bodily injury liability limits on this policy
Other: Per person Per accident

Deductible (if applicable):    Additional premium for selected UM/UIM limits: $

Stacking Options (if available):
Allow stacking of UM/UIM limits across covered vehicles
Do not allow stacking

Coverage Limitations and Exclusions

UM and UIM coverages are subject to the terms, conditions, exclusions and limits contained in the policy. Typical exclusions include, but are not limited to, claims arising while the insured was engaged in the commission of a felony, using a vehicle without a reasonable belief of permission, or injuries covered by workers' compensation. This election does not modify liability coverage or reduce third-party legal rights except as expressly set forth in the policy.

By selecting lower limits or rejecting UM/UIM coverage, the insured acknowledges that recovery for injuries caused by uninsured or underinsured motorists may be reduced or eliminated. This form constitutes the insured's written election or rejection for the policy period indicated above and will remain in effect until changed in writing in accordance with the policy's modification procedures.

Beneficiary / Payee Designation (if applicable)

In the event UM or UIM payments are payable to a designated person or representative, list the payee. If payments are to the insured, indicate "Insured".

Declaration and Certification

I hereby declare that the information provided on this form is true and correct to the best of my knowledge. I understand the nature and effect of my election or rejection of UM and UIM coverage as indicated above. I acknowledge that I have been given the opportunity to select coverage limits and deductibles and that my signature below is my informed written election. I authorize the insurer to amend the policy to reflect this election or rejection for the period shown above, subject to policy terms.

I further certify that I have read and understand the exclusions and limitations set forth in this form and in the policy. If the insured is a business entity, the signatory warrants that they have authority to bind the entity.

Applicant Printed Name:

By (Signature):

Date:

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What the Insurance UM and UIM Option Form Is

The Insurance UM and UIM Option Form documents a consumer’s selection or rejection of Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverage offered with an automobile policy. It records coverage limits chosen, any voluntary rejection of these coverages, and the insured’s acknowledgement that options were presented. Insurers commonly attach this form to new policies, renewals, and endorsement transactions so the insured’s coverage preferences are explicit, auditable, and retained for regulatory compliance and claims handling.

Why this form matters for insurers and policyholders

The form creates a clear, contemporaneous record of the insured’s UM/UIM election or rejection, reducing later disputes about available coverage. Properly completed forms support underwriting decisions, claims adjudication, and state insurance department audits while satisfying record-retention and consumer disclosure expectations under ESIGN and state law.

Why this form matters for insurers and policyholders

Who completes and reviews the UM/UIM Option Form

Maintain the completed form with the policy file so underwriting and claims teams can reference the insured’s election.

  • Insurance producers and agents who must present options and record the insured’s choice.
  • Policyholders and named insureds who must sign to accept or decline UM/UIM coverage.
  • Underwriters and claims examiners who rely on the form to confirm coverage limits and consent.

Core sections to include on a professional UM/UIM Option Form

A complete form balances clarity for the consumer with fields required for underwriting and compliance. The six elements below are standard on professionally prepared forms.

Insured identity

Named insured, policy number, and insured address to match the policy record and avoid attribution errors during claims or audits.

Coverage options

Clear presentation of UM and UIM limit choices (e.g., $25,000/$50,000) with checkbox controls for each selectable option to document intent.

Rejection checkbox

A distinct, signed rejection option for UM and/or UIM that the insured must check to decline coverage, including a place for initials if required.

Effective date

The date coverage selection or rejection takes effect, shown as MM/DD/YYYY, aligning the election with policy issuance or renewal.

Producer details

Agent/producer name, license number, and contact information so regulators can verify presentation and consumers can seek clarification.

Signature block

Signature, printed name, title (if corporate), and date; may include witness or notary lines where state law requires additional authentication.

Essential data elements to record

Insured name: Full legal name
Policy number: Carrier policy ID
Selected limits: Numerical limit values
Rejection status: Yes or No
Signature date: MM/DD/YYYY
Producer info: Agent name/license

Step-by-step: completing and retaining the UM/UIM Option Form

Follow these steps to ensure the selection is valid, auditable, and linked to the correct policy record.

  • 01
    Present options: Agent presents UM/UIM options at issuance or renewal.
  • 02
    Record selection: Complete coverage limits and check rejection boxes where applicable.
  • 03
    Obtain signature: Have insured sign and date the form; capture agent details.
  • 04
    File with policy: Store the completed form in the policy folder and digital record.

How to configure the form for online completion

Configure fields, signer roles, and authentication before sending to capture valid consent and reduce errors during e-submission.

Field Configuration
Document upload PDF or DOCX; preserve form layout
Signer roles Named insured and agent roles
Authentication Email or SMS code; use stronger checks for consent
Template save Save reusable template for renewals

Typical routing and submission flow

A straightforward e-submission flow keeps records consistent and supports auditability.

  • Upload form: Carrier uploads template to the signing platform
  • Assign signers: Add insured and agent email addresses
  • Signer completes: Insured fills and signs electronically
  • Archive copy: Signed PDF and audit trail stored in policy file

Delivery options, integrations, and technical formats

Ensure the chosen platform offers audit trails, secure storage, and API connectors to reduce manual handling and preserve chain of custody.

  • File formats: PDF, DOCX accepted
  • Integrations: Salesforce, NetSuite, Google Workspace
  • Authentication: Email link, SMS code, stronger as needed

Timing: when the UM/UIM election should be recorded

Record the insured’s election at key transaction points so coverage intent is contemporaneous and defensible.

At policy issue:

Complete form before policy is effective

At renewal:

Present options for each renewal term

On endorsement:

Capture any limit changes or rejections

Before claims:

Have form on file before processing related claims

Retention start:

Start retention from signature date

Common mistakes to avoid when preparing the form

  • Failing to match the insured name exactly to the policy record causes identification and claims delays.
  • Allowing unsigned rejections or unchecked boxes creates ambiguity about the insured’s true election.
  • Using inconsistent limit formats (words vs numbers) interferes with automated ingestion and can misstate coverage.
  • Not retaining the signed copy in the policy file complicates audits and regulatory inquiries.

Consequences of incorrect or missing UM/UIM election records

Coverage disputes: Denial or contest
Regulatory fines: Administrative sanction risk
Premium adjustments: Retroactive premium changes
Claims delays: Longer adjudication time
Reputational harm: Customer dissatisfaction
Legal exposure: Contract litigation risk

Comparing eSignature vendors for completing the UM/UIM Option Form

Key vendor criteria for form completion: price, trial availability, bulk send, audit trail, and HIPAA support. signNow is listed first for clarity in vendor comparisons.

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

Real-world examples of electronic form use

These examples illustrate how organizations use e-signed forms to simplify signings and maintain compliance with audit trails.

Optica Ventures LLC

Optica implemented e-forms across customer touchpoints to simplify signatures.

  • "The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers."
  • The result was faster document turnaround and clearer records for internal teams.

Fertility Centers of Illinois

A healthcare provider standardized consent and coverage forms electronically to reduce paper handling.

  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."
  • Standardized electronic records improved accessibility and audit readiness.

Practical tips for accurate and efficient completion

Adopt consistent practices to reduce error rates and support audits when using the UM/UIM Option Form.

Standardize templates and formats
Use a single approved template across the organization, lock critical fields, and require numeric limit formats to enable automated processing and reduce transcription errors.
Capture signer authentication
Record signer email, IP address, or SMS verification to support attribution and reduce disputes about whether the insured consented to a selection.
Link to policy records
Ensure the form includes the policy number and is stored with the policy in the document management system so underwriters and claims staff can retrieve it quickly.
Train agents and staff
Provide brief training on presenting UM/UIM options and completing the form to minimize unsigned rejections and inconsistent entries.

Frequently asked questions about the UM/UIM Option Form

Answers to common questions about e-signing, notarization, rejection documentation, and recordkeeping for UM/UIM elections.


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