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

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

Please indicate your choice by initialing next to the appropriate items and signing below:

**(Initials)**

I reject Bodily Injury Uninsured/Underinsured Motorists Coverage and select ONLY Property Damage Uninsured/Underinsured Motorists Coverage at the following limit:

**(Choose one:**

| (Initials) | Property Damage |
|-----------|-----------------|
|           | $ 25,000        |
|           | 50,000          |
|           | 100,000         |

**(Other)**

Signature of Applicant/Named Insured

Date

**D. Rejection Of BOTH Bodily Injury Uninsured/Underinsured Motorists Coverage AND Property Damage Uninsured/Underinsured Motorists Coverage**

By initialing and signing below, you are rejecting Bodily Injury Uninsured/Underinsured Motorists Coverage AND Property Damage Uninsured/Underinsured Motorists Coverage in its entirety.

**(Initials)**

I reject BOTH Bodily Injury Uninsured/Underinsured Motorists Coverage AND Property Damage Uninsured/Underinsured Motorists Coverage.

Signature of Applicant/Named Insured

Date

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© ISO Properties, Inc., 2005

IL U 040 08 05

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