Notice Regarding Amount of Underinsured

NOTICE REGARDING AMOUNT OF UNDERINSURED

MOTORIST COVERAGE AVAILABLE

Underinsured Motorist Coverage provides protection for losses and damages if injury is caused by the negligence of a driver who does not have enough insurance to pay for all losses and damages. This coverage can be included in your policy in amounts equal to or less than the limits of liability for bodily injury.

If you have elected not to reject Underinsured Motorist protection under this policy, the policy will include Underinsured Motorist Coverage in an amount equal to the limits of liability for bodily injury unless you request the issuance of Underinsured Motorist Coverage in a lesser amount. You may, for a reduced premium, select lower limits for Underinsured Motorist Coverage in an amount less than the limit of liability for bodily injury.

UNDERINSURED MOTORIST COVERAGE (CHOOSE ONE OF THE FOLLOWING BY INITIALING THE LINE NEXT TO YOUR SELECTION).

I wish to purchase Underinsured Motorist Coverage in an amount equal to the limits of liability for bodily injury.

I wish to purchase reduced Underinsured Motorist Coverage in the amount of $15,000 per person/$30,000 per accident. I understand that a reduced premium will be charged for this decrease in Underinsured Motorist Coverage which is below the limits of liability for bodily injury.

I wish to purchase reduced Underinsured Motorist Coverage at a limit of $ per person/$ per accident (cannot exceed the limits of liability for bodily injury). I understand that a reduced premium will be charged for a decrease in coverage below the limits of liability for bodily injury.

I do not wish to purchase any Underinsured Motorist Coverage.

The undersigned signature constitutes evidence that the above selections represent the undersigned's request in writing for the issuance of Underinsured Motorist Coverages in the amount set forth. This selection represents the expressed agreement and acquiescence on the part of the undersigned to obtain the coverage selected. The undersigned further states that he/she has read this entire form and all options set forth in the form and has initialed the line to the left of the coverage limits selected.

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Date Signature of Named Insured

THE OPTIONS EXPRESSED ON THIS FORM SHALL CONTINUE IN FORCE AND EFFECT UNTIL REPLACEMENT WRITTEN NOTICE IS RECEIVED BY THE COMPANY, OR ITS REPRESENTATIVE.

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