Insurance UM-UIM Document

UM/UIM COVERAGE SELECTION & ACKNOWLEDGMENT

Insurer Name:   Policy Number:

APPLICANT / INSURED INFORMATION

POLICY DETAILS

Agent / Producer:

UM / UIM COVERAGE SELECTION

The following describes Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverages. These coverages provide protection for bodily injury and, where indicated, property damage when you are legally entitled to recover from a driver who has insufficient or no liability insurance. By indicating your selection below you acknowledge the terms, limits, and conditions set forth in this document.

I elect UM/UIM bodily injury coverage.

Limits (per person / per accident): /

I elect UM property damage coverage.    Limit:    Deductible:

Stacked coverage (combine limits from multiple policies/vehicles where permitted)
Non-stacked coverage (limits apply per policy/vehicle only)

COVERAGE LIMITS / PREMIUM EFFECT

You acknowledge that the selection or rejection of UM/UIM coverages and the limits chosen may affect premium charged. The limits you select above represent the maximum amounts payable under this policy subject to all terms, conditions, exclusions, reductions, and offsets described herein.

EXCLUSIONS, OFFSET AND SUBROGATION

Exclusions: UM/UIM coverage will not apply where the insured is the at-fault driver, where the insured's conduct is excluded by the policy (including but not limited to intentional acts, use of vehicle for hired transport when not covered, or use by an excluded operator), or where recovery is barred by law. Coverage is subject to all other policy exclusions and conditions.

Offset / Setoff: Any amounts recovered from the tortfeasor, uninsured motorist, or other collateral sources may reduce the amount payable under UM/UIM coverage to the extent allowed by law. The insurer reserves the right to subtract amounts for which the insured has been or will be compensated.

Subrogation: The insurer retains subrogation rights against any at-fault party to the extent of payments made under UM/UIM coverage. The insured must cooperate with the insurer in the pursuit of recovery and must not prejudice those rights.

ARBITRATION / DISPUTE RESOLUTION

Arbitration: If a dispute arises between the insured and the insurer concerning coverage, liability, or amount of loss under UM/UIM coverage, and the policy contains an arbitration provision, both parties may submit the dispute to binding arbitration as provided in the policy. Election of arbitration may affect rights to judicial review as set forth in that provision.

By selecting arbitration in the policy, you acknowledge you have read and understand the arbitration provision if presented, and that arbitration may limit certain remedies available in court.

ACKNOWLEDGMENT OF ELECTION / REJECTION

I affirm that I have been offered UM and UIM coverages as described above and that I have read and understand the nature and effect of my selection(s). Where I have declined any coverage I do so voluntarily with knowledge that my uninsured/underinsured risk may not be covered by this policy.

I accept the UM/UIM selections indicated above.
I decline UM/UIM coverage in whole or in part as indicated.

SETTLEMENT PAYEE / BENEFICIARY (OPTIONAL)

If you wish settlement proceeds to be payable to a designated payee or beneficiary, provide the name, relationship, and percentage allocation below. Such designation does not alter rights of creditors or lienholders unless expressly permitted under the policy and applicable law.

INSURED DECLARATION & CERTIFICATION

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that my election or rejection of UM/UIM coverage is effective as of the Effective Date of Selection provided above and is subject to the terms, conditions, limitations, and exclusions set forth in the policy. I understand that any false statement or omission may be grounds for denial of coverage or rescission of the policy as provided by law and the policy terms.

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