# WEST VIRGINIA OPTIONAL EXCESS UNDERINSURED MOTOR VEHICLE COVERAGE OFFER (SINGLE LIMITS)

**IL U 016 09 03**

**Applicant/Named Insured:**

**Company:**

Below are different limits and the _______ month premium available to you.

**COMPANY MUST COMPLETE THE BLANK SPACES BELOW TO CREATE AN EFFECTIVE OFFER AND IN ORDER FOR THE CONSUMER TO EXERCISE A KNOWING AND INTELLIGENT SELECTION OR REJECTION.**

**AGENT**

**POLICY/BINDER NUMBER**

| SINGLE LIMITS | PREMIUM | I SELECT (CHECK ONE) |
|---------------|---------|----------------------|
| MANDATORY OFFER (No Less Than Liability Coverage) | $ [A] | $ [A] | [A] |
| ALTERNATIVE OFFER (Any Other Limit Available) | $ [B] | $ [B] | [B] |
| REJECT | REJECT | REJECT | [C] | I REJECT |

**IL U 016 09 03**

© ISO Properties, Inc., 2003

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