# West Virginia Optional Excess Uninsured Motor Vehicle Coverage Offer (Single Limits)

**IL U 013 09 03**

## Applicant/Named Insured:
[Name]

## Company:
[Company Name]

Below are different limits and the _______ month premium available to you.

**COMPANY MUST COMPLETE THE BLANK SPACES BELOW TO CREATE AN EFFECTIVE OFFER AND IN ORDER FOR THE CONSUMER TO EXERCISE A KNOWING AND INTELLIGENT SELECTION OR REJECTION.**

**AGENT**
**POLICY/BINDER NUMBER**

| SINGLE LIMITS | PREMIUM | I SELECT (CHECK ONE) |
|---------------|---------|----------------------|
| MANDATORY OFFER (No Less Than Liability Coverage) | [A] $ | [A] $ | [A] | ☐ |
| ALTERNATIVE OFFER (Any Other Limit Available) | [B] $ | [B] $ | [B] | ☐ |
| [C] REJECT | [C] REJECT | [C] | ☐ | I REJECT |

**IL U 013 09 03**
© ISO Properties, Inc., 2003
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