What does 'UM' mean and why is it offered?

UM stands for Uninsured/Underinsured Motorist coverage. It protects insureds when another driver lacks sufficient liability coverage; insurers are required in many states to offer or disclose this coverage.

Can the rejection be signed electronically?

Yes, where state law permits. Electronic signatures are generally valid under ESIGN (15 U.S.C. ch. 96) and UETA, provided intent, consent, attribution, and retention requirements are met.

When is notarization needed?

Notarization is uncommon for UM rejections but some states or company policies may require it. Verify state rules or your insurer’s compliance requirements before assuming none is needed.

How can a signed form be revoked or changed?

Revocation or reversal depends on policy terms and state regulation. A signed rejection can sometimes be superseded by a later signed election; maintain clear versioning and dated records.

What happens if the form is incomplete?

Incomplete or ambiguous forms may be treated as no valid election, potentially exposing the insurer and insured to coverage disputes; obtain completion promptly and document follow-up attempts.

How long should signed forms be kept?

Retain the completed form for the policy term plus additional years per company policy, IRS rules, and HIPAA if applicable; many insurers keep records seven years post-termination.

Electronic Signature
Templates
Insurance
Insurance UM Rejection Form

Insurance UM Rejection Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE UM REJECTION FORM

Applicant / Insured Information

Insured Full Legal Name Insured Address

Date of Birth

Contact Phone

Contact Email

Policy Details

Insurer / Company Name Policy Number

Policy Type: Personal Auto Motorcycle Commercial Auto Other

Policy Period From To

Offered UM Limit

Offered UIM Limit

Premium for UM/UIM (annual)

Coverage Election / Rejection

I have been offered Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverage and hereby elect the options below. I acknowledge that the insurer has explained the availability and cost of these coverages.

I DO NOT want Uninsured Motorist (UM) bodily injury coverage.

I DO NOT want Underinsured Motorist (UIM) bodily injury coverage.

I elect lower limits than those offered. Selected UM limit: Selected UIM limit:

I decline stacking of UM/UIM benefits where available under multiple vehicles or policies.

I decline UM property damage coverage (where separately offered).

Reason for Rejection or Reduced Limits (optional)

Exclusions and Important Notices

By electing to reject or limit UM/UIM coverage, the insured understands and acknowledges the following substantive provisions:

- UM/UIM coverage does not apply to intentional acts, willful misconduct, or punitive damages where prohibited by law. Coverage may be limited for vehicles used in certain commercial operations or excluded for vehicles not listed on the policy. Certain jurisdictions limit recovery where an insured is the owner or operator of a motor vehicle not insured under this policy.

- This written rejection applies to the insured named above and is effective as of the later of the policy effective date or the date signed below. Rejection of coverage may reduce or eliminate recovery for personal injury arising from accidents involving uninsured or underinsured motorists.

Declaration and Certification

I, the undersigned insured, declare under penalty of perjury and by my signature below that:

1. I have been offered Uninsured Motorist and Underinsured Motorist coverages and the opportunity to purchase specified limits. I have had the opportunity to review the limits and premium associated with such coverages.

2. I knowingly, voluntarily, and intentionally decline or select the limits as indicated above and understand the legal consequences of this election.

3. I understand that this election may be revoked or changed only by written request accepted by the insurer and that state law may provide a statutory period in which certain elections may be rescinded.

Additional Comments (optional)

For Company Use Only

Agent / Company Representative (printed name)

Agent License / ID No.

Date Received

File / Transaction No.

Applicant Name:

By:

Date:

What the Insurance UM Rejection Form Is

The Insurance UM Rejection Form documents a policyholder's decision to decline or waive Uninsured/Underinsured Motorist (UM) coverage offered by an insurer. It creates a written record establishing that the insured was offered UM protections, understood the coverage, and knowingly rejected it. The form typically identifies the policyholder, the insurer and policy number, the coverage options presented, the choice made, signature and date, and any statutory disclosure language required by state insurance regulators. Proper completion reduces future disputes about consent and coverage scope.

Why this Form Matters for Coverage and Recordkeeping

An executed UM Rejection Form documents informed refusal, helps insurers and insureds avoid claim disputes, and creates an auditable record for regulatory compliance. Under ESIGN (15 U.S.C. ch. 96) and UETA, a valid electronic signature can establish the same legal effect as a handwritten signature where allowed by state law.

Who Typically Completes or Receives the UM Rejection Form

The UM Rejection Form is used by people and teams across the insurance lifecycle to document a policyholder's choice.

Individual policyholders who elect to decline UM coverage at issuance or renewal.
Insurance agents and brokers documenting verbal explanations and recording client election.
Claims and underwriting staff who verify coverage after a loss or during policy review.

The completed form is retained by the insurer and provided to the insured; accurate completion reduces downstream disputes and compliance risk.

Essential Elements to Include on a Professional UM Rejection Form

A complete UM Rejection Form contains standardized sections so the decision is clear, traceable, and legally defensible.

Policyholder Identity

Full legal name, mailing address, and contact details for the insured so the rejection is clearly attributable to a specific person or entity.

Insurer and Policy

Insurer name and policy number plus effective dates to tie the election to the exact insurance contract and period of coverage.

Coverage Options

Clear statement of the UM limits offered and the specific coverage the policyholder declined, including numeric limits where applicable.

Statutory Disclosure

Required state-specific disclosure language and an acknowledgment that the policyholder received and understood the offer.

Signature and Date

Signature block for the insured (and agent if applicable) with date; for electronic versions include signature method and authentication used.

Record Details

Fields for agent name, agent license ID, witness or notary block when required, and an internal audit trail reference number.

Step-by-Step: Completing and Submitting the Form

Follow these four steps to ensure a valid, auditable rejection is recorded and retained.

01

Gather Documents: Collect the policy declaration, ID, and agent details before starting.
02

Fill Fields: Enter names, policy number, coverage declined, and effective date carefully.
03

Authenticate Signature: Sign in person, notarize if required, or use an approved e-sign method.
04

Submit and Store: Send to insurer records and keep a certified copy for the insured.

Typical Processing Flow for a UM Rejection Form

This high-level flow shows how the form moves from offer to archived record in a typical insurer workflow.

Offer Presentation: Agent presents UM options at issuance or renewal with required disclosures.
Decision Recorded: Policyholder signs the rejection form in paper or electronic form.
Carrier Acceptance: Insurer logs the form into policy file and updates coverage flags.
Retention: Completed form is retained according to regulatory retention rules.

How to Configure an Electronic Workflow for the Form

Set up these workflow elements to automate collection, verification, and storage of the rejection form.

Field	Configuration
Authentication	Email link, SMS code, or stronger KBA as required by state or company policy
Template	Lock required fields and include statutory disclosure language to prevent edits
Notifications	Automatic confirmations to insured and internal records group after signing
Archive	Automated PDF/A archival with audit trail metadata for retention

Technical Considerations for eSigning and eSubmission

Verify that the eSignature platform supports secure authentication, audit trails, and the file formats required by your records system.

File Formats: PDF, DOCX supported for upload and final signed output
Integrations: Connectors for CRM and document storage (Salesforce, NetSuite, Google Workspace)
Compliance: ESIGN/UETA compliance plus audit trail and encryption

Timing: When to Offer, Execute, and Record the Form

Timing obligations can depend on state law and company practice; confirm with your state Department of Insurance or legal counsel.

Offer Timing:

Typically presented at policy issuance or renewal; must be documented at or before coverage start

Execution Window:

Signed at the time of election; delayed signatures may not retroactively alter coverage

Post-Claim Review:

Insurer may require the recorded election when evaluating UM claims

Agent Recordkeeping:

Agents should retain a copy per company retention policy and state rules

State Confirmation:

Check state DOI guidance for any statutory deadlines or required forms

Key Milestones from Offer to Archive

Track these milestones as discrete stages so each party’s responsibility is clear and auditable.

01

Offer Presented

Agent provides statutory disclosure and available limits to the applicant.

02

Choice Documented

Policyholder signs the UM Rejection Form; signature and date captured.

03

Carrier Logging

Insurer logs the form into the official policy file and updates systems.

04

Archive Retained

Completed form is retained according to regulatory and company retention schedules.

Common Preparation and Submission Errors to Avoid

Leaving required statutory disclosure text out, which can render the election invalid and reopen coverage disputes.
Mismatching names or policy numbers that prevent the form from being tied to the correct policy record.
Accepting initials or informal marks where a full signature is required by company or state rules.
Failing to retain an audit trail or certificate of completion for electronic signatures, weakening proof of consent.

Risks and Potential Consequences of an Incorrect Form

Coverage Dispute: Claim denials or disputes if election lacks valid proof of informed consent

Regulatory Action: State DOI inquiries or fines for noncompliance with disclosure requirements

Reinstatement Risk: Courts or regulators may reinstate UM coverage if waiver is invalid

Reputational Harm: Agent or insurer exposure from mishandled consumer elections

Operational Cost: Increased claims handling and legal costs to resolve documentation gaps

Data Privacy: Improper handling of sensitive data can trigger HIPAA or state privacy investigations

How the UM Rejection Form Differs from Similar Documents

Compare the UM Rejection Form with related consumer election or waiver documents to clarify purpose and legal effect.

Criteria	UM Rejection	Coverage Waiver
Purpose	decline um coverage	modify or limit coverage
Legal effect	creates written refusal	alters coverage terms
Signature required		often yes
Notarization	rare	rare

eSignature Vendor Comparison for Electronic UM Rejection Forms

Compare representative plan features and starting prices for common eSignature providers used to collect signed UM Rejection Forms.

	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 trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Practical Examples of Using the UM Rejection Form

These two scenarios illustrate standard uses and the importance of an auditable record for policyholder elections.

Agent Issuance Example

An agent presents UM options at renewal

Agent records the policyholder’s visual acknowledgement
The signed electronic form is stored with the policy and timestamped to prevent later dispute.

Claims Verification Example

A claims adjuster requests coverage confirmation after a collision

The insurer retrieves the signed rejection form
The audit trail documents the election and expedites claims handling decisions.

FAQs and Troubleshooting for the UM Rejection Form

Answers to common questions about acceptance, electronic execution, revocation, and recordkeeping for the UM Rejection Form.

Need help? Contact support

What does 'UM' mean and why is it offered?
UM stands for Uninsured/Underinsured Motorist coverage. It protects insureds when another driver lacks sufficient liability coverage; insurers are required in many states to offer or disclose this coverage.
Can the rejection be signed electronically?
Yes, where state law permits. Electronic signatures are generally valid under ESIGN (15 U.S.C. ch. 96) and UETA, provided intent, consent, attribution, and retention requirements are met.
When is notarization needed?
Notarization is uncommon for UM rejections but some states or company policies may require it. Verify state rules or your insurer’s compliance requirements before assuming none is needed.
How can a signed form be revoked or changed?
Revocation or reversal depends on policy terms and state regulation. A signed rejection can sometimes be superseded by a later signed election; maintain clear versioning and dated records.
What happens if the form is incomplete?
Incomplete or ambiguous forms may be treated as no valid election, potentially exposing the insurer and insured to coverage disputes; obtain completion promptly and document follow-up attempts.
How long should signed forms be kept?
Retain the completed form for the policy term plus additional years per company policy, IRS rules, and HIPAA if applicable; many insurers keep records seven years post-termination.

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