# Uninsured and Underinsured Motorists Coverage Selection/Rejection Form
**New Hampshire**

## Commercial Excess/Umbrella Coverage Forms

**Applicant/Named Insured:**
_____

**Policy Number:**
_____

**New Hampshire law requires the offering of Uninsured and Underinsured Motorists Coverage under Excess Liability Coverage forms. Uninsured/Underinsured Motorists Coverage is insurance which pays persons insured under our policy who are injured in an accident caused by an owner or operator of an uninsured or underinsured motor vehicle. If coverage is selected, the limit shown as the Commercial Auto Liability Limit on your policy declarations is excess over any underlying insurance provided.**

Place a checkmark in the block for the coverage option you desire. The Company will issue your policy in accordance with the coverage options selected.

- [ ] UNINSURED/UNDERINSURED MOTORISTS COVERAGE AT LIMITS EQUAL TO THE UMBRELLA/EXCESS AUTOMOBILE LIABILITY LIMIT
- [ ] I REJECT UNINSURED/UNDERINSURED MOTORIST COVERAGE UNDER THIS POLICY

The choice you make will apply to all renewal, continuations, and changes to your policy unless you notify your agent or broker in writing. If you have any questions about your coverage, ask your agent or broker.

The undersigned understands the offers described and has made an informed decision with regards to the coverage options offered in this form.

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**Applicant/Named Insured:**
_____

**Date:**
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XS-11534 (3/02) Ptd. In U.S.A.

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