If you would like to reject Bodily Injury Uninsured Motorists Coverage equal to your Bodily Injury Liability Coverage limits or Combined Single Limit for Liability Coverage and select lower limits, please indicate your choice by initialing and signing below:

(I) Initials) I REJECT Bodily Injury Uninsured Motorists Coverage equal to my Bodily Injury Liability Coverage limit or Combined Single Limit for Liability Coverage and select the following lower limit(s).

(Choose one):

(I) Initials) Split Limits Bodily Injury OR (I) Initials) Combined Single Limit

$ 50,000/100,000 $ 100,000
100,000/200,000 200,000
100,000/300,000 250,000
250,000/500,000 300,000
300,000/300,000 350,000
500,000/1,000,000 500,000
1,000,000/1,000,000 1,000,000
(Other) (Other)

Signature of Applicant/Named Insured Date
Signature of Applicant/Named Insured Date
Signature of Applicant/Named Insured Date

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