UNINSURED MOTORIST COVERAGE SELECTION/REJECTION - Signature Required
You may be electing not to purchase certain valuable coverage which protects you and your family or you may be purchasing Uninsured Motorist limits less than your Bodily Injury Liability limits when you sign this form. Please read carefully.
Georgia law requires that automobile policies include Uninsured Motorist Coverage (Added On) to At-Fault Liability Limits with limits equal to the Liability limits provided in your policy. However, it also requires that you be provided with the option to select Uninsured Motorist Coverage (Reduced) by At-Fault Liability Limits, select lower limits offered by the company, or reject Uninsured Motorist coverage entirely.
Uninsured Motorist Coverage Notice
If you have chosen to accept Uninsured Motorists coverage from your automobile insurance company, and have any questions after reading this statement regarding Uninsured Motorists coverage or the amount of coverage you have selected, your agent or company representative will be able to assist you. You should have chosen the amount of Uninsured Motorists coverage you want based on this question: If I get hit by someone with little or no liability insurance, how much protection do I need to cover the cost associated with car repair, medical bills, other expenses, and lost wages? If you accept Uninsured Motorist Coverage (Added On), once the at-fault party's Liability limits are exhausted, you may collect from your policy an amount equal to the remaining damages you suffer up to your Uninsured Motorist Coverage limit. If you elect to select Uninsured Motorist Coverage (Reduced), your total automobile insurance recovery (from all companies involved) may not exceed the limit of Uninsured Motorist (Reduced) coverage you chose.
The purpose of this notice is informational. This notice does not change or replace the wording in your policy.
COVERAGE SELECTION
Uninsured Motorist Coverage limits must be uniform on all vehicles. Please make your Uninsured Motorist Coverage selection below.
Uninsured Motorist Coverage for all vehicles
1.  I want Uninsured Motorist Coverage (Added On) equal to my Liability Coverage limits. With this selection, I acknowledge that I am purchasing certain valuable coverage which protects myself and my family and I am not purchasing limits less than Liability limits.
2.  I select Uninsured Motorist Coverage (Added On) but reject limits equal to my Liability Coverage limits. Instead, I select the following limits:
Limits: ______/______
3.  I reject Uninsured Motorist Coverage (Added On) but select Uninsured Motorist Coverage (Reduced) equal to my Liability Coverage limits.
4.  I reject Uninsured Motorist Coverage (Added On) but select Uninsured Motorist Coverage (Reduced) at limits less than my Liability Coverage limits. I select:
Limits: ______/______
5.  I reject both Uninsured Motorist Coverage (Added On) and Uninsured Motorist Coverage (Reduced) in their entirety.
I understand and agree that the selection of any of the above options applies to all future renewal and amendment policies which are issued at the same Bodily Injury Liability limits. If I decide to select another option, I must complete another Uninsured Motorist Selection/Rejection Form. By my signature below, I confirm that I have read and understand Uninsured Motorist Coverage limit options.
APPLICANT'S SIGNATURE POLICY #:______
______
Applicant /
DATE:
______
OMNI GA UMSEL (01/09)