If you would like to reject Bodily Injury Uninsured Motorists Coverage equal to your Bodily Injury Liability Coverage limits or Combined Single Limit for Liability Coverage and select lower limits, please indicate your choice by initialing and signing below:

(I) Initials) I REJECT Bodily Injury Uninsured Motorists Coverage equal to my Bodily Injury Liability Coverage limit or Combined Single Limit for Liability Coverage and select the following lower limit(s).

(Choose one)

| (Initials) | Split Limits | Bodily Injury | OR | (Initials) | Combined | Single Limit |
|-----------|--------------|---------------|----|------------|----------|--------------|
|           | $            | 50,000/100,000 |    |           | $        | 100,000      |
|           |              | 100,000/200,000 |    |           |          | 200,000      |
|           |              | 100,000/300,000 |    |           |          | 250,000      |
|           |              | 250,000/500,000 |    |           |          | 300,000      |
|           |              | 300,000/300,000 |    |           |          | 350,000      |
|           |              | 500,000/1,000,000 |   |           |          | 500,000      |
|           |              | 1,000,000/1,000,000 |  |           |          | 1,000,000    |
|           | (Other)      |               |    |           | (Other)  |             |

Signature of Applicant/Named Insured

Date

Signature of Applicant/Named Insured

Date

Signature of Applicant/Named Insured

Date

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© Insurance Services Office, Inc., 2009
IL U 069 04 10
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