# Supplementary Commercial Automobile Application

## Tennessee Excess or Umbrella Policies

**(To be completed and signed by Named Insured)**

**Name:** International Business Machines Corporation  
**Policy Number:** 7FSJEX-218T033-A-91  
**Address:** Old Orchard Rd., Armonk, N.Y.

## Protection Against Uninsured Motorists

Tennessee law requires that if you have selected Uninsured Motorists Bodily Injury Coverage equal to the Bodily Injury Liability Limits on your primary policy, your excess or umbrella policy shall automatically include coverage for damages for bodily injury which the insured may be entitled to recover from the owner or operator of an uninsured or underinsured motor vehicle, at the same limits as the bodily injury liability excess or umbrella policy limits, unless you reject said coverage or select lower limits as indicated below.

Please indicate how you wish your coverage to apply by checking the proper box and sign the space below:

- I wish to elect Uninsured Motorists Coverage at limits less than the bodily injury liability limits of my excess or umbrella policy.
  (Specify) $_________

- X I wish to reject Uninsured Motorists Bodily Injury coverage on my excess or umbrella policy.

Note: Your selections only apply as indicated above with respect to your excess or umbrella policy.

I have personally reviewed and completed the above items. Please provide full coverage except where I have specifically rejected a coverage or selected an optional amount of coverage.

**Signature of Named Insured:** ________________  
**Date:** ________________

**Agent:** ______________________  
**Date:** ______________________