# Rejection Of Property Damage Uninsured/Underinsured Motorists Coverage And Selection Of ONLY Bodily Injury Uninsured/Underinsured Motorists Coverage

By completing this section, you are rejecting Property Damage Uninsured/Underinsured Motorists Coverage and selecting ONLY Bodily Injury 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 reject Property Damage Uninsured/Underinsured Motorists Coverage and select ONLY Bodily Injury Uninsured/Underinsured Motorists Coverage at limits equal to my Bodily Injury Liability Coverage (split limits) or Combined Single Limit for Liability Coverage.
OR

2. I reject Property Damage Uninsured/Underinsured Motorists Coverage and select ONLY Bodily Injury Uninsured/Underinsured Motorists Coverage at the following limit(s):

**(Choose one:)**

| Split Limits Bodily Injury | Combined Single Limit |
|---------------------------|-----------------------|
| $50,000/100,000           | $100,000              |
| $100,000/300,000          | $200,000              |
| $250,000/500,000          | $250,000              |
| $300,000/500,000          | $300,000              |
| $500,000/1,000,000        | $350,000              |
| $500,000/1,000,000        | $500,000              |
| $1,000,000/1,000,000      | $1,000,000            |
| $1,000,000/2,000,000      | $2,000,000            |

**(Other)**

**Signature Of Applicant/Named Insured**

**Date**

IL U 040 08 05
© ISO Properties, Inc., 2005
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