Can this form be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the signer consents to electronic records and the platform captures an audit trail.

Is notarization required for signature validity?

Typically no for claim submissions, but some insurers or states may require notarization or a witnessed signature for certain authorizations; confirm with the insurer or state law.

What supporting documents should accompany the form?

Attach the police report, itemized medical bills, repair estimates, and any other documentation the form requests to prevent processing delays and substantiate damages.

How do I correct a mistake after signing?

Do not alter a signed copy. Complete a corrected form with a new signature or submit an amendment per insurer instructions and retain both versions for the record.

Who is authorized to sign as a representative?

An authorized representative must have written proof of agency (power of attorney or written authorization). Insurers typically require documentation of representation before accepting signatures.

How long should signed forms be kept?

Retain records for the active claim period and for at least the applicable federal or state retention period (see HIPAA 45 CFR §164.530(j) and IRS rules such as IRC §6501(a)).

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!

Insurance UM/UIM Form

Use this form to elect, reject, or modify Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverage available under the listed policy. The insured acknowledges receipt of the offer of UM/UIM coverage and makes the election indicated below. Selections made on this form will apply to the policy and policy period shown unless otherwise amended in writing.

Insured / Applicant Information

Insured Name Date of Birth Address

Phone:

Email:

Policy Information

Insurer / Company Name

Policy Number:

Agent / Producer:

Policy Period From:

Policy Period To:

Policy Type Liability Limit (per person / per accident)

UM / UIM Coverage Offer and Election

The insurer offers UM/UIM coverage. The default offered limit is equal to the liability limit of the policy unless the insured affirmatively selects otherwise below.

Coverage Election (check one)

I accept UM/UIM coverage at limits equal to my liability limits shown above.

I accept UM/UIM coverage with lower limits of $ per person / per accident.

I reject UM/UIM coverage entirely and understand that I will not have UM/UIM protection under the policy.

Stacking and Deductible Options

I elect stacking of UM/UIM limits across insured vehicles where stacking is permitted by law.

I elect non-stacked UM/UIM limits (single policy limit applies).

I elect a UM/UIM deductible of $ to apply to UM/UIM settlements where permitted by the policy.

Estimated additional premium for elected UM/UIM selection: $

Exclusions and Limitations

UM/UIM coverage does not apply to injuries or damages arising while the insured is using a vehicle without a reasonable belief of permission, to vehicles used as public or livery conveyances when excluded by policy, to punitive or exemplary damages in excess of compensatory damages where excluded by law, or as otherwise set forth in the policy. The insurer retains all rights of subrogation and the insured's election does not waive the insurer's subrogation or recovery rights, except as expressly provided by statute or policy.

Arbitration of disputes may be required by the policy. By electing coverage the insured acknowledges that some disputes may be subject to binding arbitration as set forth in the policy language.

I acknowledge that I have read and understand the exclusions and limitations summarized above and in the policy.

I acknowledge that arbitration may apply to UM/UIM disputes as provided in the policy.

I acknowledge the insurer's subrogation rights and duties under the policy.

Beneficiary Designation for Death Benefits

If UM/UIM death benefits are payable under the policy, designate payee(s) below. If no beneficiary is designated, payment will be made in accordance with the policy and applicable law.

Beneficiary Name

Relationship:

Allocation %:

Claim Reporting (for notice purposes)

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

Police report filed: Yes

Certification and Signature

By signing below I certify that the information provided on this form is true and correct to the best of my knowledge. I understand my selections regarding UM/UIM coverage will control for the policy period indicated unless I submit a written request to change coverage in accordance with the terms of the policy. I acknowledge that rejecting or reducing UM/UIM coverage may limit the protection available to me and my family and that I have been given the opportunity to select limits equal to my liability limits.

I further acknowledge that the insurer's obligations and any arbitration, subrogation, or other dispute-resolution provisions are set forth in the policy contract, and my election here is subject to those contractual provisions.

Applicant Name:

Signature:

Date:

What the Insurance UM/UIM Form Is and When it Applies

The Insurance UM/UIM Form records a claimant's uninsured motorist (UM) and underinsured motorist (UIM) claim details, policy information, and supporting facts needed for an insurer to evaluate payment. It typically captures policy numbers, accident date and location, involved parties, injury and vehicle damage descriptions, medical provider details, and authorization to obtain records. Insurers use this form to determine coverage eligibility, calculate benefit amounts, and coordinate benefits with third-party liability carriers. The form may be used by policyholders, claimants, or third-party representatives and often accompanies medical bills, police reports, and repair estimates.

Why a Properly Completed UM/UIM Form Matters

Accurate completion reduces claim delays, supports correct coverage decisions, and preserves rights under state insurance law. Electronic completion and retention meet legal standards under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; consumer-facing disclosures may be required for financial or healthcare-related records.

Who Typically Prepares and Signs this Form

Parties that commonly complete the Insurance UM/UIM Form range from insured drivers to claims adjusters and attorneys; the section below lists typical users.

Policyholders and claimants — provide accident facts, policy numbers, and consent to records release for claim evaluation.
Insurance adjusters and agents — review entries, request supporting documents, and use the form to open or deny claims.
Attorneys and third-party representatives — submit completed forms when pursuing claims or coordinating settlements on behalf of a client.

Ensure the person completing the form signs in the correct role (claimant, authorized representative, or witness) and that name spelling matches government ID and policy records.

Step-by-Step: Complete and Submit the UM/UIM Form

Follow these core steps to prepare a complete UM/UIM claim submission that supports timely review and payment.

01

Gather Documents: Collect police report, medical records, repair estimates, and policy declarations.
02

Fill Required Fields: Enter names, policy numbers, accident date, and injury summary accurately.
03

Sign Authorization: Sign and date; grant authorization to obtain medical or billing records.
04

Submit and Track: Send to insurer and retain proof of submission and a copy of the signed form.

How Electronic Submission Typically Works

Electronic workflows speed exchange and create an audit trail; common steps mirror paper processes while adding digital authentication and storage.

Upload Document: Sender uploads the UM/UIM form and attachments to the claims portal or eSignature service.
Prepare Fields: Designate required fields, signature blocks, and record-release checkboxes before sending.
Authenticate Signer: Use email/SMS code or stronger authentication depending on insurer policy and regulator needs.
Store Audit Trail: System captures timestamps, IP, and completion evidence for later review.

Recommended Digital Workflow Settings for UM/UIM Submissions

Configure these settings when preparing the form for eSignature or online submission to ensure compliance and traceability.

Field	Configuration
Authentication	Email link or SMS code; use KBA for higher assurance.
Required Fields	Mark policy, accident date, and signature as required.
Conditional Logic	Show additional fields when injuries are reported or third-party claims exist.
Retention Location	Secure cloud storage with audit trail and export options.

Technical Options for Digital Signing and Delivery

Choose a platform that supports required authentication, secure storage, and evidence capture for claims handling.

Document Formats: Support for PDF and DOCX for reliable rendering.
Integrations: Connectors for claims systems and cloud storage (e.g., CRM, Box).
Audit Trail: Timestamps, IP, and signer metadata retained.

Ensure the chosen platform can produce a reproducible copy and maintain chain-of-custody metadata for regulatory or litigation needs.

Essential Elements to Include on a Professional UM/UIM Form

A comprehensive form combines claimant identity, incident data, authorization language, and clear signature fields; each element supports accurate adjudication and potential subrogation.

Claimant Identification

Full legal name, date of birth, contact details and claimant role establish identity and allow the insurer to match records to policyholder files and treatment providers.

Policy and Insurer Details

Exact policy number, named insured, and carrier name let carriers verify coverage, limits, and whether UM/UIM applies under the insured's policy terms.

Accident and Loss Description

Detailed date, time, location, weather, and narrative of events provide facts for liability assessment and assist in coordinating benefits with third-party carriers.

Medical and Repair Information

List providers, treatment dates, billing totals, and repair shop estimates to support damage and injury valuation and to streamline subrogation and payment calculations.

Authorization and Records Release

A clear HIPAA-compliant authorization for medical records and a tax-authorization if applicable allow the insurer to obtain necessary documentation without repeated requests.

Signature and Role

Designated signature blocks for claimant, policyholder, or authorized representative with date and printed name avoid ambiguity about signer authority and consent to the release.

Security, Privacy, and Compliance Details to Note

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Audit Trail: Time-stamped events and signer metadata

HIPAA Support: BAA required for PHI handling

Regulatory Standards: ESIGN and UETA legal compliance

Access Controls: Role-based permissions and SSO

Exportability: Reproducible signed PDF with certificate

Penalties and Risks from Incomplete or Incorrect Forms

Claim Denial: Insurer may deny or reduce benefits

Processing Delays: Missing data triggers additional requests

Coverage Gaps: Incorrect policy info can misapply limits

Subrogation Loss: Inadequate details harm recovery rights

Fraud Exposure: False statements can lead to prosecution

Administrative Fines: Regulatory penalties for record failures

Common Preparation Mistakes to Avoid

Leaving policy number or insurer name blank; this forces rework and delays claim intake and coordination.
Using incorrect date formats or approximate dates; inconsistent dates can complicate liability timelines and medical treatment sequencing.
Failing to attach police reports or medical bills; missing attachments often lead to requests for more information and slower resolutions.
Mismatch between signer name and identification; identity mismatches can require notarization or additional verification steps.

Timelines and Typical Deadlines for UM/UIM Claims

Timelines vary by insurer and state; prompt notice and timely documentation preserve rights and prevent avoidable denials.

Initial Notice:

Provide notice to insurer as soon as possible; many carriers expect notification within days of the loss.

Medical Authorization:

Return signed authorizations within insurer-requested timeframe to avoid processing holds.

Proof Submission:

Submit bills, estimates, and police reports promptly when requested to support coverage decision.

Statute of Limitations:

State law sets suit filing deadlines; verify state-specific limits with counsel to avoid forfeiture.

Retention of Originals:

Keep originals until claim closure plus recommended retention period for audits or disputes.

Comparison: eSignature Vendor Pricing and Core Capabilities

Common eSignature plans differ by starting price, trial availability, bulk-send capabilities, and compliance options. signNow is listed first for comparison purposes.

	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	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About the Insurance UM/UIM Form

Answers to common questions about e-signing, notarization, corrections, and retention for UM/UIM claim forms.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the signer consents to electronic records and the platform captures an audit trail.
Is notarization required for signature validity?
Typically no for claim submissions, but some insurers or states may require notarization or a witnessed signature for certain authorizations; confirm with the insurer or state law.
What supporting documents should accompany the form?
Attach the police report, itemized medical bills, repair estimates, and any other documentation the form requests to prevent processing delays and substantiate damages.
How do I correct a mistake after signing?
Do not alter a signed copy. Complete a corrected form with a new signature or submit an amendment per insurer instructions and retain both versions for the record.
Who is authorized to sign as a representative?
An authorized representative must have written proof of agency (power of attorney or written authorization). Insurers typically require documentation of representation before accepting signatures.
How long should signed forms be kept?
Retain records for the active claim period and for at least the applicable federal or state retention period (see HIPAA 45 CFR §164.530(j) and IRS rules such as IRC §6501(a)).

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