Rejection of Uninsured Motorists Coverage

SELECTION AND/OR REJECTION OF UNINSURED AND UNDERINSURED MOTORISTS COVERAGE
(IOWA)

Iowa Insurance Law (Section 516A.1), permits you, the insured named in the policy, to reject Uninsured Motorists Coverage and/or Underinsured Motorists Coverage. Uninsured Motorists Coverage and Underinsured Motorists Coverage provide for the protection of persons insured under the policy who are legally entitled to recover damages from the owner or operator of an uninsured motor vehicle (hit-and-run motor vehicle) or an underinsured motor vehicle because of bodily injury, sickness, or disease, including death resulting therefrom.

The following notice is required by the Iowa Insurance Division:

NOTICE REGARDING UNINSURED/UNDERINSURED COVERAGE

Uninsured/underinsured coverage does not cover damage done to your vehicle. It provides benefits only for bodily injury caused by an uninsured or underinsured motorist. If you wish to be insured for damage done to your vehicle, you must have collision coverage. Please check your policy to make sure you have the coverage desired.

In accordance with the above, the undersigned insured –

(Mark applicable item “X”)

Agrees to SELECT the following limits of Uninsured Motorists Bodily Injury Coverage:

$ combined single limit per accident

Agrees to SELECT the following limits of Underinsured Motorists Bodily Injury Coverage:

$ combined single limit per accident

Agrees to REJECT Uninsured Motorists Coverage only.

Agrees to REJECT Underinsured Motorists Coverage only.

Agrees to REJECTboth Uninsured AND Underinsured Motorists Coverage.

PLEASE READ BEFORE SIGNING

I hereby acknowledge that:

(1) I understand the difference between the options available to me.

(2) The selection I make here, where applicable, will be binding on me and all named insureds under my Policy, despite any information to the contrary in the application for insurance, and will be in effect for every extension, reinstatement, substitution, amendment, alteration, modification, transfer, replacement or renewal of my Policy, unless I request, in writing, a different option.

(3) Regardless of the number of vehicles involved, whether insured or not, persons covered, claims made, premiums paid or the number of premiums shown on the policy, in no event shall the limit of liability for 2 or more vehicles or 2 or more policies be added together, combined or stacked to determine the limits of insurance coverage available to injured persons.

______By: ______

COMPANY (NAME/NAMED INSURED) SIGNATURE

______

PRINT NAME AND TITLE DATE

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