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.)

Dick Devine

Insurance Producer

Dick Devine has 49 years of experience as an Independent Agent in Personal Lines, Commercial Lines, Life & Health Insurance Coverages.

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

Check only one of the following check boxes

Disclosures and Comments

Dick Devine

RiskRevu^TM Newsletter

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

Check only one of the following check boxes

Disclosures and Comments

Dick Devine

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RiskRevuTM Newsletter

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