SELECTION AND/OR REJECTIONOF UNINSURED/UNDERINSUREDMOTORIST COVERAGE
(Texas)

Uninsured and UnderinsuredMotorist Coverage protects insureds who are legally entitled to recover damages from owners or operators of uninsured or underinsured motor vehicles due to bodily injury, sickness, disease or death, or property damage resulting from the ownership, maintenance or use of any such motor vehicle.

The Texas Insurance Code requires that every automobile liability insurance policy that covers liability arising out of the ownership, maintenance or use of a motor vehicle contain Uninsured or Underinsured Motorist Coverage in the policy unless an insured named in the policy rejects the coverage in writing. If the coverage is not rejected, the limits of liability afforded must be at least equal to the minimum limits required by the Texas Motor Vehicle Safety Responsibility Act, but not higher than the policy’s liability limit.

If you wish to rejectany or all of the Uninsured/Underinsured Motorist Coverage offered to you, please complete Section A below. If you wish to purchaseany or all of such coverage, please complete Section B.

A. REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE

In accordance with the Texas Insurance Code, the undersigned insured, and each of them (applicable item marked “X”):

rejects the offer of both Uninsured/Underinsured Motorist Bodily Injury Liability and Property Damage Coverages.

rejects the offer of Uninsured/Underinsured Motorist Bodily Injury Liability Coverage only.

rejects the offer of Uninsured/Underinsured Motorist Property Damage Coverage only.

B. SELECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE

In accordance with the Texas Insurance Code, the undersigned insured, and each of them (applicable item marked “X”):

selects the following limitsof Uninsured/Underinsured Motorist Bodily Injury Liability Coverageonly:

$ / each person Bodily Injury
$ / each accident Bodily Injury

selects the following limit of Uninsured/ Underinsured Motorist Property Damage Coverage only:

$ / each accident Property Damage

selects the following combined single limit of Uninsured/Underinsured Motorist Bodily Injury Liability and Property Damage Coverages:

$ / each accident Bodily Injury and Property Damage

PLEASE READ BEFORE SIGNING

In accordance with my selection and/or rejection of coverage above, I hereby acknowledge that I understand the difference between the options available to me. I also understand that 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.

______By: ______

COMPANY (NAMED INSURED) SIGNATURE

______

PRINT NAME AND TITLE DATE

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