# State of Nevada
Uninsured/Underinsured Motorists
Coverage Selection Form

## Umbrella Liability Coverage Form
## Excess Liability Coverage Form

The UM/UIM statute requires umbrella insurers to obtain a signed disclosure statement indicating whether the policy includes uninsured or underinsured motorists coverage. The disclosure statement must be on a form provided by the commissioner or in substantially the following form:

### UMBRELLA POLICY DISCLOSURE STATEMENT
#### UNINSURED/UNDERINSURED VEHICLE COVERAGE

- Your Umbrella Policy **does provide** coverage in excess of the limits of the uninsured/underinsured vehicle coverage in your primary auto insurance only if the requirements for the uninsured/underinsured vehicle coverage in your underlying auto insurance are maintained. The minimum uninsured/underinsured vehicle coverage in your umbrella insurance policy is $__________. The limits of the uninsured/underinsured vehicle coverage in your primary auto insurance policy are $__________.
- I understand and acknowledge the above disclosure.

Insured: _______________________________
Date: _______________________________

- Your Umbrella Liability Policy **does not provide** any uninsured/underinsured vehicle coverage.
- I understand and acknowledge the above disclosure.

Insured: _______________________________
Date: _______________________________

XS-15509 (5/04)

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