# 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 OR Combined Single Limit

| (Initials) | Split Limits Bodily Injury | (Initials) | 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               |
|           | 500,000/500,000          |           | 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)                                             (Other)

Signature Of Applicant/Named Insured                  Date
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