# Selection Of Bodily Injury Uninsured/Underinsured Motorists Coverage AND Property Damage Uninsured/Underinsured Motorists Coverage

By completing this section, you are selecting BOTH Bodily Injury Uninsured/Underinsured Motorists Coverage AND Property Damage Uninsured/Underinsured Motorists Coverage in connection with your automobile liability policy.

Please indicate your choice by initialing next to the appropriate item(s) in 1. OR 2. and signing below:

## Initials

1. I select Bodily Injury Uninsured/Underinsured Motorists Coverage AND Property Damage Uninsured/Underinsured Motorists Coverage at limits equal to my Liability Coverage.
OR
2. I select Bodily Injury Uninsured/Underinsured Motorists Coverage AND Property Damage Uninsured/Underinsured Motorists Coverage at the following limit(s):
(Choose one Split Limits Bodily Injury option AND one Property Damage limit option, OR one Combined Single Limit option from the following:)

### Split Limits Bodily Injury
| (Initials) | $50,000/100,000 | (Initials) | $25,000 |
|-----------|-----------------|-----------|---------|
|           |                 |           |         |
|           | 100,000/300,000 |           | 50,000  |
|           |                 |           |         |
|           | 250,000/500,000 |           | 100,000 |
|           |                 |           |         |
|           | 300,000/500,000 |           |         |
|           |                 |           |         |
|           | 500,000/500,000 |           |         |
|           |                 |           |         |
|           | 500,000/1,000,000|           |         |
|           |                 |           |         |
|           | 1,000,000/1,000,000|           |         |
|           |                 |           |         |
|           | 1,000,000/2,000,000|           |         |

### Combined Single Limit
| (Initials) | $125,000 |
|-----------|---------|
|           | 200,000 |
|           | 250,000 |
|           | 300,000 |
|           | 350,000 |
|           | 500,000 |
|           | 1,000,000 |
|           | 2,000,000 |

## Other
- **Bodily Injury**
- **Property Damage**

## Signature Of Applicant/Named Insured
## Date

**Page 2 of 4**
© ISO Properties, Inc., 2005
IL U 040 08 05

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