# Selection or Rejection of Uninsured/Underinsured Motorists Property Damage Coverage (Louisiana)

The Louisiana Insurance Code, Section R.S. 22:1295, provides that if you have selected Uninsured Motorists Coverage and your automobile liability policy does not afford collision coverage, you may select Uninsured/Underinsured Motorist Property Damage Coverage. Uninsured/Underinsured Motorists Property Damage Coverage provides insurance for the protection of persons insured under the policy who are legally entitled to recover damages from the owner or operator of an uninsured or underinsured motor vehicle because of property damage to the motor vehicle described in the policy arising out of the operation, maintenance, or use of the uninsured/underinsured motor vehicle. Coverage shall be in the amount of the actual cash value of such motor vehicle described in the policy or $25,000, whichever is less, subject to a deductible of $250 for any one accident.

If you have rejected Uninsured Motorist Coverage you are not eligible for Uninsured/Underinsured Motorist Property Damage Coverage.

In accordance with the Louisiana Insurance Code (Section R.S. 22:1295), amended, the undersigned insured (and each of them):

**(Applicable item marked "X")**

- ☐ I SELECT Uninsured/Underinsured Motorists Property Damage Coverage. This means Uninsured/Underinsured Motorists Property Damage Coverage WILL be included in my policy.
- ☐ I REJECT Uninsured/Underinsured Motorists Property Damage Coverage. This means Uninsured/Underinsured Motorists Property Damage Coverage WILL NOT be included in my policy.

I/we understand and agree that I/we personally have made the selection above with my/our own hand(s) after being made aware of my choices as described above, and the selection made will be applicable to the vehicles described in the policy and any substitute or replacement vehicles and all future renewals until I/we make a written request for additional coverage or a change in coverage from what was selected above.

**Premium Adjustment (if any)**

$ ____________

Signature of Insured
Date _______________

Signature of Insured
Policy No. (if known) _______________

UA198a (01-10) © 1998 Wolters Kluwer Financial Services | Uniform Forms™