Insurance UM UIM Selection Form

INSURANCE UM / UIM SELECTION FORM

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Type: Private Passenger Auto Commercial Auto Motorcycle Other

Policy Period — Effective:    Expiration:

UM / UIM Coverage Selection

The undersigned elects the following Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverages for the above policy. Selections below will be incorporated into the policy declarations and are binding upon issuance or amendment of the policy.

I hereby elect (check one): Accept UM/UIM coverage as indicated below Decline UM/UIM coverage entirely

UM Bodily Injury Limit — Per Person: $    Per Accident: $

UIM Bodily Injury Limit — Per Person: $    Per Accident: $

UM Property Damage Limit: $    Deductible (if any): $

Stacking of Limits: Stacked limits (combine limits across insured vehicles as permitted) Unstacked limits (limits apply per vehicle)

Exclusions, Limitations, and Election Consequences

By initialing and signing below, the applicant acknowledges that UM/UIM coverage typically excludes coverage for: intentional acts by the insured, use of the vehicle for hire where excluded by endorsement, non-covered drivers specifically excluded by endorsement, vehicles not declared on the policy, and incidents occurring outside the territory defined by the policy. Election to decline or limit UM/UIM coverage may reduce or eliminate recovery for injury or damage resulting from uninsured or underinsured motorists.

Subrogation, Arbitration, and Other Provisions

Subrogation: The insurer retains the right to pursue subrogation or reimbursement from any third party responsible for loss to the extent of payments made under UM/UIM coverages, unless specifically waived in writing. Applicant may elect to waive subrogation only where permitted by state law and insurer endorsement.

Arbitration: Claims under UM/UIM coverages may be subject to arbitration as set forth in the policy. By selecting the arbitration agreement below, the insured consents to binding arbitration of disputes as described in the policy language.

Beneficiary / Payment Designation (Optional)

If proceeds under UM/UIM coverage are payable as death benefits, designate payee(s) below. This designation applies only to payment of death benefits and does not alter other rights under the policy unless expressly accepted by the insurer.

Claim Reporting / Documentation

In the event of a loss involving UM/UIM coverage, the insured must provide prompt notice, cooperate with reasonable claim investigation, and supply documentation of loss and damages. The insurer may require medical records, police reports, proof of loss, and proof of uninsured/underinsured status of other parties.

Certification and Applicant Acknowledgment

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that my elections regarding UM and UIM coverages will control the coverage provided under the policy as permitted by law and subject to the policy terms and any endorsements. I understand that declining or reducing UM/UIM limits may limit my ability to recover for losses caused by uninsured or underinsured drivers.

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