Can the UM form be signed electronically?

Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; ensure the consumer disclosure is presented when required and the signature is attributable and retained.

Is a notary or witness always required?

Not necessarily. Witness and notary requirements vary by state and the specific carrier form; check state law or the insurer's instructions to determine if notarization or witnesses are mandatory.

What if the insured initials but does not sign?

Initials alone may be insufficient unless the form explicitly allows them. A full signature and date provide clearer attribution and reduce the risk of disputes.

How long should signed forms be retained?

Retain signed forms for the policy term plus applicable statutory periods. Federal guidance: retain tax-related records at least three years; HIPAA-related items six years when applicable.

Can an agent sign on behalf of the insured?

An agent may sign only if they have delegated authority or a valid power of attorney accepted by the carrier. Carriers commonly require documentation of that authority.

What to do if a signer uses an incorrect policy number?

Correct the policy number immediately and reverify the signed selection with the insured. Maintain both versions and a note explaining the correction to preserve an audit trail.

Electronic Signature
Templates
Insurance
Insurance Uninsured Motorist Coverage Form

Insurance Uninsured Motorist Coverage Form

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

INSURANCE UNINSURED MOTORIST COVERAGE FORM

Applicant / Insured Information

Client Name:

Mailing Address

Date of Birth:

Phone:

Email

Policy Details

Insurer Name

Policy Number:

Policy Type:

Policy Period From:

To:

Annual Premium:

Deductible:

Policy Territory:

Uninsured / Underinsured Motorist Coverage Options

Select the uninsured/underinsured motorist (UM/UIM) coverages to apply to this policy. If you decline UM/UIM coverage, sign the acknowledgement below.

Coverage Selections Accept Uninsured Motorist Bodily Injury Accept Underinsured Motorist Bodily Injury Accept Uninsured Motorist Property Damage Combined Single Limit (CSL)

Bodily Injury Limit Per Person:

Bodily Injury Limit Per Accident:

Property Damage Limit:

Stacking Option:

Optional Election / Rejection I decline uninsured/underinsured motorist coverage and understand that by declining I may be waiving statutorily available protection.

Exclusions and Limitations

The following exclusions apply to UM/UIM coverage unless specifically endorsed: claims by permissive users for business use of a vehicle excluded from the policy, intentional injury caused by the insured, vehicles owned by the insured but not listed on the policy (unless otherwise endorsed), and any claim barred by law or public policy.

Acknowledge exclusion: intentional acts and criminal conduct Acknowledge exclusion: vehicles not listed on policy Acknowledge exclusion: claims barred by other coverages or law

Beneficiary / Claim Payee Information

Provide the primary payee for any UM/UIM settlement under this policy.

Payee Name

Relationship:

Allocation Percentage:

Claims Notice and Cooperation

The insured must provide prompt notice of loss, cooperate with the insurer in investigation and litigation, and provide requested documentation. Failure to provide required notice or cooperation may affect coverage.

Designated Claim Contact

Declaration and Certification

By signing this form the applicant certifies under penalty of perjury that the information provided is true and correct to the best of the applicant's knowledge. The applicant further acknowledges receipt of the notice of available uninsured and underinsured motorist coverage, understands the coverage limits selected above, and understands the legal effect of declining such coverage if the decline option is selected.

The applicant authorizes the insurer to obtain records relevant to underwriting and claims handling and agrees that any dispute concerning coverage shall be decided pursuant to the policy terms, conditions, and applicable law. The applicant understands that signing below constitutes a binding election or rejection of UM/UIM coverage as indicated on this form.

Additional Remarks

Applicant Name:

Signature:

Date:

Certification: I certify that I have read and understand the selections made on this form and that my election or rejection of uninsured/underinsured motorist coverage is made knowingly and voluntarily.

What the Insurance Uninsured Motorist Coverage Form Is

The Insurance Uninsured Motorist Coverage Form documents a policyholder's selection, rejection, or limits for uninsured/underinsured motorist protection under an auto insurance policy. It records coverages and limits, evidences informed consent or waiver where required by state law, and becomes part of the insured's file for claims and regulatory review. Carriers, agents, and insureds use this form to show whether UM/UIM protection is in force, the dollar limits chosen, and any signed declination consistent with insurer and statutory requirements.

Why this form matters to insurers and insureds

The form creates an auditable record of a policyholder's UM/UIM selection or rejection, reduces disputes at claim time, and supports carrier regulatory compliance. It clarifies coverage limits and effective dates for both underwriting and claims handling.

Who typically prepares and signs this form

Accurate completion ensures consistent coverage interpretation, faster claims handling, and a clear compliance trail for regulators.

Insurance agents and brokers who collect coverage elections during new business or renewal transactions.
Policyholders or named insureds who accept or decline UM/UIM coverage and choose limits.
Claims and underwriting staff who rely on the form to confirm coverage at the time of loss.

Who can sign on behalf of the insured

Named Policyholder

The individual or entity listed as the insured may sign. For individuals, use the exact legal name on identification; for entities, the authorized officer must sign and provide title and corporate authority documentation when requested.

Authorized Agent

An agent or attorney-in-fact with a valid power of attorney may sign if the carrier accepts delegated authority. The carrier may require the POA document or other evidence of signing authority before honoring elections or waivers.

Core elements found on a professional UM coverage form

A well-designed form combines clear coverage choices, policy identifiers, signature blocks, and legal notices so selections are unambiguous for claims and compliance reviewers.

Policy Identifiers

Policy number, named insured, vehicle VIN or description, and effective policy period so the selection ties to a specific contract.

Coverage Options

Presentation of available UM/UIM limits and checkboxes or radio buttons to clearly show the chosen limit or rejection option.

Declaration/Waiver

Explicit language confirming acceptance or rejection of coverage and any state-mandated disclosure text the insured must acknowledge.

Effective Date

A clearly labeled effective date field that determines when the chosen selection becomes operative for the policy.

Signature Block

Printed name, signature, signer role, date signed, and signer contact information for attribution and validation.

Carrier Notices

Regulatory or consumer-disclosure language required by the insurer or state insurance department regarding UM/UIM options.

Step-by-step: complete and submit the UM coverage form

Follow these steps to ensure the form is valid, attributable, and accepted by the insurer.

01

Gather documents: Collect policy number, vehicle details, and ID before you start.
02

Choose option: Select the UM/UIM limit or sign the explicit rejection box.
03

Sign and date: Provide a signature and complete the date field in MM/DD/YYYY.
04

Submit to carrier: Return the form via the carrier's accepted channel and retain a copy.

Recommended digital workflow settings for eCompletion

Configure your online workflow to capture consent, authenticate signers, and retain an audit trail for compliance.

Field	Configuration
Consumer Disclosure	Present ESIGN consumer disclosure when the form is consumer-facing
Signer Authentication	Use email link or SMS code; stronger KBA if state or carrier requires
Signature Type	Allow typed or drawn signature; require explicit signed checkbox for waivers
Audit Trail	Capture IP, timestamp, and actions for every signer event

Technical prerequisites for secure eSubmission

Ensure retention and export capabilities meet your recordkeeping policies and regulatory requirements.

Browser and TLS: Modern browser with TLS 1.2+ required
File formats: PDF or DOCX preferred; maintain original pagination
Integrations: Connectors for CRM or policy systems recommended

Typical electronic completion and submission flow

A standard eSubmission process reduces processing time and preserves an audit trail for regulatory review.

Upload form: Sender uploads a PDF or DOCX copy to the signing platform.
Place fields: Insert signature, date, and selection fields where required.
Invite signer: Send secure email or SMS link to the policyholder.
Capture audit trail: Platform logs timestamps, IP addresses, and actions.

When to complete and return the form

Timely completion depends on whether the election occurs at issuance, renewal, or midterm change.

At new business:

Provide the form with the initial application to document coverage choices.

At renewal:

Complete any change or reaffirmation when the policy is renewed.

Midterm changes:

Submit the form promptly when altering coverage outside renewal.

Before effective date:

Ensure the effective date matches carrier requirements to avoid coverage gaps.

Retain signed copy:

Keep a copy for your records and for claims support.

Processing milestones from completion to claim readiness

Sequence of milestones insurers and policyholders typically follow after form completion.

01

Form Completion

Policyholder completes and signs the UM selection or waiver.

02

Carrier Intake

Carrier or agent records selection in policy management system.

03

File Attachment

Signed form is attached to the policyholder file and retained.

04

Claim Reference

Form is used to verify coverage at time of claim adjudication.

Common mistakes to avoid when preparing the form

Leaving multiple coverage boxes checked creates conflicting elections and may invalidate the selection.
Using initials instead of a full signature when the form requires a signed acknowledgement.
Entering an incorrect policy number that prevents the carrier from locating the related policy file.
Failing to capture a dated signature or using an ambiguous effective date that causes coverage disputes.

Risks and consequences of an incomplete or incorrect form

Coverage Gap: Claims denial or reduced recovery

Regulatory Issue: State market conduct review

Claim Delay: Longer investigation and payment timelines

Audit Failure: Missing documentation for exams

Incorrect Limits: Reduced payout at settlement

Authority Dispute: Signatures challenged by third parties

Real-world examples of how organizations handle UM forms

These short examples show common approaches to collecting and storing selections.

Optica Ventures LLC

Optica uses a digital form to collect policy elections during onboarding and stores them in the policy system

The team captures an audit trail for each signer
This approach simplified verification during claims and helped streamline underwriting workflows without in-person paperwork.

Fertility Centers of Illinois

The center integrated e-sign workflows to collect insurance authorizations and coverage acknowledgements

Signatures are captured with time stamps and IP addresses
That integration reduced administrative follow-up and provided a clear record for both patient billing and insurer audits.

Electronic submission versus paper delivery

A concise comparison of eSubmission and paper methods for the UM coverage form.

Criteria	eSubmission	Paper
Legally binding
Notarization needed	varies by state	sometimes required
Consumer disclosure	often required	n/a
Audit trail		limited

Typical eSignature vendor pricing and compliance overview

Compare starting prices, trial availability, bulk send, audit trail, and HIPAA compliance across common eSignature providers. SignNow is listed first per vendor comparison requirements.

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

Notarization and witness authentication workflow

When notarization or witness authentication is required, follow a clear multi-step process to validate identity and preserve evidence.

01

Prepare Document

Ensure form fields and signature blocks are finalized before notarization.

02

Identity Proofing

Signer presents ID or completes KBA per notary or RON rules.

03

Witness Presence

Arrange required witnesses to observe signing if state mandates them.

04

Notary Acknowledgement

Notary completes the acknowledgment and signs/notarizes the document.

05

RON Recording

For remote notarization, retain audio-video session as required.

06

Attach Journal Entry

Notary record or journal entry should be stored per state rules.

07

Attach to Policy File

Carrier attaches notarized form to the insured's policy record.

08

Retain Evidence

Keep notarization records for the legally required retention period.

Frequently asked questions about the UM coverage form

Answers to common questions about validity, eSigning, witness needs, and recordkeeping for uninsured motorist elections.

Need help? Contact support

Can the UM form be signed electronically?
Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; ensure the consumer disclosure is presented when required and the signature is attributable and retained.
Is a notary or witness always required?
Not necessarily. Witness and notary requirements vary by state and the specific carrier form; check state law or the insurer's instructions to determine if notarization or witnesses are mandatory.
What if the insured initials but does not sign?
Initials alone may be insufficient unless the form explicitly allows them. A full signature and date provide clearer attribution and reduce the risk of disputes.
How long should signed forms be retained?
Retain signed forms for the policy term plus applicable statutory periods. Federal guidance: retain tax-related records at least three years; HIPAA-related items six years when applicable.
Can an agent sign on behalf of the insured?
An agent may sign only if they have delegated authority or a valid power of attorney accepted by the carrier. Carriers commonly require documentation of that authority.
What to do if a signer uses an incorrect policy number?
Correct the policy number immediately and reverify the signed selection with the insured. Maintain both versions and a note explaining the correction to preserve an audit trail.

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