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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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.)
Cecilia Rivera
860-868-7361
http://ericsoninsurance.com/
Cecilia_Rivera@ajg.com
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