# Supplementary Commercial Automobile Application

## Uninsured Motorist Coverage - Bodily Injury
**Louisiana**

## Excess or Umbrella Policies

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

**Name:** IBM Corporation  
**Address:** Old Orchard Road, Armonk, N.Y. 10504

### 1. Uninsured Motorists - Bodily Injury

Uninsured motor vehicle include:
1) motor vehicles for which there is no liability insurance.
2) motor vehicles for which the available limits for liability insurance is not enough to pay the full amount of damages (Underinsured Motor Vehicle).
3) hit-and-run vehicles.

In accordance with Louisiana Statutes, Uninsured Motorists Insurance which provides coverage for damages for bodily injury which the insured may be entitled to recover from the owner or operator of an uninsured motor vehicle, must be provided on your Excess or Umbrella policy at limits equal to such policy's bodily injury liability limits.

You do have the option to reject this coverage or select limits which are lower than the Bodily Injury Limits on such policy. Do have

Please indicate your desired options by checking the appropriate box and signing the form below:

- **1. Uninsured Motorists coverage at Limits other than the Bodily Injury Liability Limits of my Excess or Umbrella policy:**
  - $__________ each accident; or
  - $__________ each person, $__________ each accident.

- **2. I hereby reject Uninsured Motorists Bodily Injury coverage on my Excess or Umbrella policy.**

### II. A. If named insured or applicant is a corporation, CORPORATE CHARTER RESOLUTION FORM CP-5796 must be completed. (On subsequent renewals or replacement of such policy, resolution will be deemed to be enforceable unless you notify us in writing that the resolution has been modified.)

B. If named insured or applicant is a partnership, the person signing below is an authorized representative, empowered and directed to sign, complete, and execute any and all Uninsured Motorists rejection forms, agreements or documents and to sign all other papers and documents and to do all of the things necessary and/or proper to give full effect to the rejection (or election) of Uninsured Motorists coverage referred to therein unless you notify us in writing of a change in authority.

**NOTE:** This form is the only acceptable evidence of your coverage selections for Uninsured Motorists Bodily Injury coverage with respect to your Excess or Umbrella policy.

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