Legal UM Rejection Form

LEGAL UM REJECTION FORM

This Legal UM Rejection Form (the "Form") is made as of Effective Date: by and between Policyholder Name: with Address: and Insurer Name: with Address: (each a "Party" and collectively the "Parties").

RECITALS

WHEREAS, Insurer is authorized under the Policy identified below to provide uninsured and underinsured motorist coverage ("UM Coverage") to persons named in the Policy; and

WHEREAS, Policyholder has been offered UM Coverage in connection with Policy Number: and has been informed of the scope, limits and conditions of such coverage; and

WHEREAS, Policyholder elects to reject UM Coverage to the extent set forth below and the Parties desire to record that election and the legal effect of that election in writing.

NOW, THEREFORE

In consideration of the mutual covenants and agreements contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

1. DEFINITIONS

For purposes of this Form: (a) "UM Coverage" means uninsured and underinsured motorist coverage as defined in the Policy; (b) "Rejection" means a voluntary, informed, and documented refusal of UM Coverage by the Policyholder; and (c) "Policy" means the insurance policy identified by Policy Number above.

2. ACKNOWLEDGMENT AND WAIVER

Policyholder acknowledges that Insurer offered UM Coverage and that Policyholder was informed in clear and conspicuous terms of the availability, scope, and limits of such coverage. Policyholder knowingly and voluntarily elects to reject UM Coverage as follows:

Rejection applies to:   Entire Policy    Specific Vehicle(s) / Named Individuals

3. SCOPE AND LEGAL EFFECT

By signing this Form, Policyholder expressly waives the right to UM Coverage to the extent indicated above. The waiver is binding on Policyholder and, to the extent permitted by law, on Policyholder's heirs, representatives, and assigns. This waiver shall not operate to alter or expand any coverage not otherwise provided under the Policy.

4. VOLUNTARINESS AND CONSULTATION

Policyholder certifies that the decision to reject UM Coverage is voluntary, that Policyholder has been given a reasonable opportunity to obtain advice from legal counsel or other advisors, and that no coercion, undue influence, or misrepresentation induced this decision.

I received a written offer describing UM Coverage terms.
I understand the terms and limitations of UM Coverage as explained to me.
I have been given the opportunity to consult with an attorney or insurance advisor.

5. INDEMNIFICATION

To the fullest extent permitted by applicable law, Policyholder agrees to indemnify, defend and hold Insurer harmless from and against any claims, losses, liabilities, costs or expenses (including reasonable attorneys' fees) arising solely from Policyholder's election to reject UM Coverage, provided that nothing in this section shall relieve Insurer of any contractual obligation under other provisions of the Policy.

6. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses set forth above by hand delivery, certified mail (return receipt requested), or other method providing proof of delivery. Notice shall be effective upon receipt.

7. AMENDMENTS; WAIVER

No amendment, modification, or waiver of any provision of this Form shall be effective unless in writing and signed by both Parties. Failure to enforce any provision shall not constitute a waiver of future enforcement of that or any other provision.

8. GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the state in which the Policy was issued, without regard to its conflicts of law principles. The Parties submit to the exclusive jurisdiction of the courts located in that state for resolution of disputes arising under this Form.

9. ENTIRE AGREEMENT

This Form constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral, concerning the rejection of UM Coverage.

10. SEVERABILITY

If any provision of this Form is held to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect and shall be construed so as to effectuate the intent of the Parties to the fullest extent permitted by law.

11. REPRESENTATIONS

Each Party represents and warrants that it has the full power and authority to enter into this Form, that the person signing on its behalf is duly authorized, and that this Form constitutes a legal, valid and binding obligation enforceable in accordance with its terms.

CERTIFICATION

By signing below, Policyholder certifies under penalty of perjury and acknowledges that: (a) the decision to reject UM Coverage was made knowingly and voluntarily; (b) Policyholder has read and understands this Form; and (c) the statements herein are true and accurate to the best of Policyholder's knowledge.

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