Group Personal Excess Liability - Uninsured/Underinsured Motorist Protection Rejection/Selection Form

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 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. *
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.)

Aida Rodriguez

Personal Risk Advisor

An experienced personal risk advisor in charge of personal insurance advisor with 32 years of personal insurance experience.

Back to Profile Share

Group Personal Excess Liability - Uninsured/Underinsured Motorist Protection Rejection/Selection Form

Check only one of the following check boxes

Disclosures and Comments

Aida Rodriguez

RiskRevu^TM Newsletter

Contact

Group Personal Excess Liability - Uninsured/Underinsured Motorist Protection Rejection/Selection Form

Check only one of the following check boxes

Disclosures and Comments

Aida Rodriguez

Share This

RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter