A named insured or applicant must select or reject coverage offered above, and complete this part of the form in his or her own handwriting.

- I have read the IMPORTANT NOTICE, attached, on UNinsured motor vehicle coverage and understand how this coverage works.
- I have been given the opportunity to select the limits of UNinsured motor vehicle coverage listed above and have selected the coverage that matches the box I have checked.
- I have been given the opportunity to select the limits of UNinsured motor vehicle coverage listed above and have rejected the coverage.

Signature Of A Named Insured Or Applicant

Date

This selection or rejection of coverage is binding on all persons covered under the policy. These limits apply until a change in the limits is requested.

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