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Group Personal Excess Liability - Uninsured/Underinsured Motorist Protection Rejection/Selection Form
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What is your first name? *
What is your first name? *
What is your last name? *
What is your last name? *
What is your email address? *
What is your email address? *
What is the sponsoring organization's name for this group personal excess liability program? *
What is the sponsoring organization's name for this group personal excess liability program? *
What is your primary home address? *
What is your primary home address? *
Street Address
Address Line 2
City
State
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Northern Mariana Islands
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Texas
Utah
U.S. Virgin Islands
Vermont
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Armed Forces Americas
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ZIP Code
What is the effective date of the group personal excess liability policy? *
What is the effective date of the group personal excess liability policy? *
MM slash DD slash YYYY
What is the name of the issuing company for this group personal excess liability policy? *
What is the name of the issuing company for this group personal excess liability policy? *
Please enter the policy period. (I.e. 7/1/2022 - 7/1/2023)
Please enter the policy period. (I.e. 7/1/2022 - 7/1/2023)
Check only one of the following check boxes
I reject excess uninsured/underinsured motorist protection entirely. By rejecting excess uninsured/underinsured motorist protection, uninsured/underinsured liability coverage will also not be included on the policy.
I reject excess uninsured/underinsured motorist protection entirely. By rejecting excess uninsured/underinsured motorist protection, uninsured/underinsured liability coverage will also not be included on the policy.
I reject UM/UIM
I elect the following amount of excess uninsured/underinsured motorists protection. I understand that the amount of excess uninsured/underinsured motorists protection I elect must be equal to or less than my excess liability coverage amount of coverage unless I request the lower amount shown below.
I elect the following amount of excess uninsured/underinsured motorists protection. I understand that the amount of excess uninsured/underinsured motorists protection I elect must be equal to or less than my excess liability coverage amount of coverage unless I request the lower amount shown below.
I eject UM/UIM
Please select the Uninsured/Underinsured Motorist coverage limit you are electing. *
Please select the Uninsured/Underinsured Motorist coverage limit you are electing. *
$1,000,000
$2,000,000
$3,000,000
$5,000,000
$10,000,000
Other
Please enter the limit of Uninsured/Underinsured Motorist coverage you are electing. *
Please enter the limit of Uninsured/Underinsured Motorist coverage you are electing. *
The group personal excess liability policy participant who is named on the coverage summary certificate can sign this form below. *
The group personal excess liability policy participant who is named on the coverage summary certificate can sign this form below. *
Please enter the date this form is being signed. *
Please enter the date this form is being signed. *
MM slash DD slash YYYY
Please enter the producing agency's name. *
Please enter the producing agency's name. *
Please enter the producing agent's name. *
Please enter the producing agent's name. *
Please enter the producing agent's phone number. *
Please enter the producing agent's phone number. *
Disclosures and Comments
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
<font size="2" color="gray">Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree *
UM/UIM Rejection/Selection Form Preview
UM/UIM Rejection/Selection Form Preview. (Click the download icon to download a copy of this form.)
Ted Mara
508-735-1423
http://ajg.com
Ted_Mara@Ajg.com
Area Vice President
Tedmund J Mara is Vice President
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