Can this be signed electronically?

Yes. Electronic signatures are generally legally binding under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are met.

Are medical records required?

Medical records are often required to substantiate injury claims; include treatment dates and provider details and provide HIPAA authorization where PHI is shared.

Is notarization necessary?

Not usually for initial claim forms, but some states or specific releases may require notarization; verify state rules and insurer instructions before notarizing.

How long until the claim is acknowledged?

Acknowledgement timelines vary by insurer but commonly occur within 15–30 days; provide complete documentation to avoid additional requests.

What if information changes after submission?

Submit an amended form or written update immediately. Document changes, include dates, and retain both originals for audit and subrogation purposes.

How to correct a signed error?

If a signed field is incorrect, prepare a correction addendum or an amended form signed by the same parties; in some cases a notarized correction may be required.

Electronic Signature
Templates
Insurance
Insurance UM UIM Form

Insurance UM UIM Form

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

Uninsured / Underinsured Motorist (UM/UIM) Coverage Selection Form

Applicant / Insured Information

Insured Name:

Mailing Address

Date of Birth:

Phone:

Email:

Policy Details

Insurance Company

Policy Number:

Policy Effective:

Policy Expiration:

Policy Type

UM / UIM Coverage Election

The undersigned elects coverage for Uninsured Motorist (UM) and Underinsured Motorist (UIM) as indicated below. Check one option for each coverage to indicate acceptance or rejection. If both boxes are left unchecked for a coverage, the election will be interpreted according to applicable policy provisions and state law.

Uninsured Motorist (UM)

Accept UM coverage
Reject UM coverage

UM Coverage Limit (select one or enter custom)

$25,000 / $50,000
$50,000 / $100,000
$100,000 / $300,000
Custom:

Underinsured Motorist (UIM)

Accept UIM coverage
Reject UIM coverage

UIM Coverage Limit (select one or enter custom)

$25,000 / $50,000
$50,000 / $100,000
$100,000 / $300,000
Custom:

Stacking, Deductible & Premium

Stacking permits combining limits from multiple insured vehicles where permitted by law. Select stacking option:

Stacking Requested
Stacking Rejected

Deductible (if applicable) Additional Premium for Selected UM/UIM

Exclusions & Important Notices

The following are common exclusions to UM/UIM coverage. A check in the box acknowledges you have read and understand that these exclusions may apply under your policy.

Intentional injury or acts committed by the insured are excluded.
Claims arising while the insured is operating a vehicle without a valid license are excluded.
Vehicles not listed on the policy or used without permission may be excluded.
Injuries arising out of excluded business or occupational use as defined by the policy are excluded.

This form does not alter other policy provisions. Coverage is subject to policy terms, conditions, limits and applicable law.

Beneficiary Designation (Death Benefits Only)

Provide primary beneficiary information for any UM/UIM death benefits payable under the policy. Percentages must total 100% for all listed beneficiaries.

Primary Beneficiary 1

Relationship:

Percentage:

Primary Beneficiary 2 (optional)

Relationship:

Percentage:

Claim Reporting (For Policyholder Reference)

In the event of an incident that may give rise to a UM/UIM claim, document the incident below and gather the listed documentation. This section is informational and does not constitute a claim form.

Date of Loss Location of Loss Description of Loss Estimated Damage / Medical Costs

Documentation Checklist:
Police report available
Photographs of damage/injury available
Medical records / bills available
Repair estimates available

Declaration and Certification

I hereby declare that the information provided on this form is true and correct to the best of my knowledge. By signing below I:

Elect or decline UM and UIM coverage as indicated above and acknowledge that such election will be incorporated into the policy subject to the terms, conditions and limits of the policy and applicable law;
Acknowledge that I have been given the opportunity to review available UM/UIM limits and options, including stacking where applicable, and understand the premium impact of my election;
Understand the exclusions described above and confirm that I have read this form in full prior to signing;
Agree that this election will remain in effect for the policy period identified unless changed in accordance with the policy provisions and applicable law.

I certify under penalty of law that the information provided on this form is complete and accurate.

Applicant:

Signature:

Date:

What the Insurance UM UIM Form Is and Who Uses It

The Insurance UM UIM Form documents a claim or election related to Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverage under an auto insurance policy. Insurers use this form to record claimant details, policy references, loss information, coverage elections, and subrogation rights. Policyholders complete the form when reporting a collision involving an uninsured or underinsured driver, requesting UM/UIM benefits, or certifying reductions or waivers. The form supports claims intake, reserves establishment, and legal preservation of rights for both first- and third-party claimants while tracking any required attachments such as police reports or medical records.

Why Accurate UM/UIM Forms Matter for Claims and Coverage

A complete Insurance UM UIM Form creates a clear administrative and legal record that speeds claim evaluation and preserves contractual and subrogation rights under the policy.

Primary Users and When They Complete the Form

Use this form when a policyholder or claimant reports a loss involving an uninsured or underinsured driver and UM/UIM coverage may apply.

Claimants and policyholders reporting UM/UIM losses to their insurer, typically after a collision where the other party lacks sufficient coverage.
Insurance adjusters and claim examiners who need standardized claimant data, loss particulars, and authorization to obtain records.
Third-party advocates or attorneys submitting documentation on behalf of clients during settlement negotiations or litigation.

Accurate completion reduces processing delays, lowers denial risk, and documents consent for record retrieval and subrogation steps.

Step-by-Step: Completing an Insurance UM UIM Form

Follow these sequential steps to fill, verify, and submit the UM/UIM form for timely processing.

01

Gather Documents: Collect police report, medical bills, and proof of other driver’s coverage.
02

Enter Claim Data: Fill claimant, policy, and loss fields carefully using MM/DD/YYYY dates.
03

Attach Evidence: Upload photos, invoices, and authorization forms required by the insurer.
04

Sign and Submit: Sign the form (physical or e-sign) and send to the insurer’s claims address or portal.

Core Sections of a Professional Insurance UM UIM Form

A well-designed UM/UIM form groups essential data into labeled sections to reduce omissions and speed evaluation.

Claimant Details

Full legal name, contact information, date of birth, driver’s license number, and relationship to insured where relevant; supports identity verification and benefits routing.

Policy Information

Insurer name, policy number, named insured, effective dates, and coverage limits so adjusters can confirm applicability and limits quickly during initial screening.

Loss Description

Date, time, location, narrative of the accident, and diagram fields to capture material facts relevant to liability and damage causation for subrogation analysis.

Injury and Damage

Fields for medical providers, treatment dates, vehicle damage estimate, and wage loss to compile a preliminary damages summary for reserves and negotiations.

Consent and Authorization

Explicit releases authorizing the insurer to obtain medical, wage, and police records; includes HIPAA-consistent language when health information is requested.

Signature Block

Signature, printed name, date, and checkboxes for attestations such as truthfulness, assignment of benefits, or waiver of recovery; must be clear and unambiguous.

Essential Data Elements for Submission

Claimant Name: Exact legal name

Policy Number: Policy identifier

Loss Date: MM/DD/YYYY

Incident Location: Street, city, state

Medical Providers: Names and dates

Signature: Signed and dated

Common Preparation Errors to Avoid

Entering a nickname or partial name that does not match government ID, which can delay verification and payment.
Using ambiguous dates or inconsistent MM/DD/YYYY formats across fields, creating confusion about the incident timeline.
Failing to attach required medical invoices, police reports, or proof of other driver’s coverage, which stalls liability evaluation.
Signing with initials only when a full signature and printed name are required, potentially invalidating attestations.

Consequences of Inaccurate or Incomplete Forms

Claim Delay: Processing is postponed

Denial Risk: Coverage may be denied

Subrogation Loss: Rights can be impaired

Payment Withholding: Benefits may be withheld

Legal Exposure: Disputes may incur costs

Regulatory Action: State penalties possible

Where to Send the Completed Insurance UM UIM Form

Route the completed form to the insurer’s designated claims channel; choose the method your insurer specifies—mail, secure portal, email to claims unit, or in-person delivery.

Insurer Portal: Upload via the company claims portal for fastest intake.
Claims Email: Send to the insurer’s claims email address if permitted.
Postal Mail: Mail original signatures to the claims address where required.
Agent Submission: Deliver to your agent or broker for handoff to the carrier.

How to Configure an Online UM/UIM Submission Workflow

Typical online workflows reduce manual steps and preserve an audit trail for each submitted UM/UIM form.

Field	Configuration
Claimant ID	Auto-validate with ID match
Attachments	Require police report and medical bills
Authentication	Email + SMS code optional
Audit Trail	Capture timestamps and IPs

Digital Signing and eSubmission Considerations

Use platforms that support secure e-signing, conditional fields, and a tamper-evident audit trail for UM/UIM forms.

File Formats: PDF, DOCX supported
Authentication: Email and optional SMS
Integrations: CRM and document storage

Timelines and Common Processing Deadlines

Adhere to timely-notice obligations in the policy and state law; prompt submission preserves coverage and subrogation opportunities.

Policy Notice Timing:

Submit as soon as possible per policy terms

Medical Record Requests:

Respond within insurer-specified timeframes, often 30 days

Claim Acknowledgement:

Insurer typically acknowledges within 15–30 days

Statute of Limitations:

Varies by state; file suit promptly if needed

Subrogation Pursuit:

Begins after liability and damages established

eSignature Pricing Comparison for UM/UIM Form Workflows

Compare common vendor starting prices and compliance features when selecting an eSignature provider for UM/UIM intake and secure attachments.

	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	No	No
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

FAQs and Troubleshooting for the Insurance UM UIM Form

Answers to frequent questions about electronic signing, attachments, notarization, and common processing issues with UM/UIM forms.

Need help? Contact support

Can this be signed electronically?
Yes. Electronic signatures are generally legally binding under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are met.
Are medical records required?
Medical records are often required to substantiate injury claims; include treatment dates and provider details and provide HIPAA authorization where PHI is shared.
Is notarization necessary?
Not usually for initial claim forms, but some states or specific releases may require notarization; verify state rules and insurer instructions before notarizing.
How long until the claim is acknowledged?
Acknowledgement timelines vary by insurer but commonly occur within 15–30 days; provide complete documentation to avoid additional requests.
What if information changes after submission?
Submit an amended form or written update immediately. Document changes, include dates, and retain both originals for audit and subrogation purposes.
How to correct a signed error?
If a signed field is incorrect, prepare a correction addendum or an amended form signed by the same parties; in some cases a notarized correction may be required.

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