# Uninsured Motorists' Coverage Option Selection Form

**Ace Group**

**YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORISTS' LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY.**

Uninsured Motorists' Coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehicles because of bodily injury or death resulting therefrom. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the policy. For the purpose of this coverage, an uninsured motor vehicle may include a motor vehicle as to which the bodily injury limits are less than your damages.

Florida law requires that automobile liability policies which do not provide primary liability insurance include Uninsured Motorists' coverage at limits up to the Bodily Injury Liability Limits in your policy or $1 million, whichever is less, or reject Uninsured Motorists' coverage entirely.

- **a. I hereby reject Uninsured Motorists' coverage.**
- **b. I hereby select Uninsured Motorists' coverage up to the liability limit of my policy but not greater than $1,000,000.**

If you have selected to purchase Uninsured Motorists' coverage under this form, coverage will be on a non-stacked basis. If injury occurs in a vehicle owned or leased by you or any family member who resides with you, this policy will apply only to the extent of coverage (if any) which applies to that vehicle in this policy. If any injury occurs while occupying someone else's vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of uninsured motorist coverage available on any one vehicle for which you are a named insured, insured family member, or insured resident of the named insured's household. This policy will not apply if you select the coverage available under any other policy issued to you or the policy of any other family member who resides with you.

I understand and agree that selection of any of the above options applies to my liability insurance policy and future renewals or replacements of such policy which are issued at the same Bodily Injury Liability limits. If I decide to select another option at some future time, I must let the Company or my agent know in writing.

**Signed:**

**Date:**

**Policy Number:**

Excess FL Supplement 61 (02/09)

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