Uninsured Motorists Coverage Selection/Rejection Form Changes

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1 Uninsured Motorists Coverage Selection/Rejection Form Changes If you have any questions, please contact our business support specialists at NM Uninsured Motorists (UM) Coverage/Quoting Changes: 1. Log in to and click on the blue PTS4 button. a. Click on New Quote link. b. Fill in the effective date c. Select Personal Auto from the drop-down menu for the line of business. d. Your state will be pre-populated. If not, select New Mexico from the drop down. e. Under Company, select Hallmark Insurance Company. f. Select the auto product you wish to quote. g. Click on green Start Quote button. NM Uninsured Motorists Coverage/Quoting Changes Page 1 of 11

2 2. Fill in customer information. Click Continue button when completed. 3. Please Note: This section of the quote process has changed. a. Make appropriate liability and medical payment coverage selections. b. Add discounts if any are applicable. c. Click Continue button. NM Uninsured Motorists Coverage/Quoting Changes Page 2 of 11

3 4. Please Note: This section of the quote process has changed. Case law makes it clear that an informed consumer choice is to be a guiding principal in whether we ve properly offered UM. We must allow the selection/rejection of UMBI and UMPD per vehicle, but if any are selected, all vehicles have coverage. If UMBI and/or UMPD is accepted on multiple vehicles, this provides stacked coverage on all vehicles. For customers who do not complete the forms, endorsements will be issued to increase the UM coverages to the maximum available on their policies. Completion of the new selection/rejection form at renewal will be required only one time for each policyholder. However, a new selection/rejection form must be executed in conjunction with each endorsement to add, replace and/or delete vehicles. To accept or reject UMBI or UMPD, please follow these steps: a. Select Year, Make and Model. (VIN number is recommended.) b. Select Deductibles and Coverage Limits: i. UMBI / UMPD / OTC / COLL / Towing / Rental / Special Equip. ii. UMBI is defaulted to accept coverage. Policyholder may reject coverage on each vehicle. UMPD is not defaulted to accept. c. Special Considerations for UMBI: i. If the customer does not want UMBI, they should reject on all vehicles. ii. If the customer wants 25/50 UMBI on all vehicles, they should accept on one vehicle and reject on all the others. iii. If the customer wants stacked UMBI coverage on all vehicles, they should accept as many vehicles as required to obtain the limits they desire. d. Special Considerations for UMPD: i. UMPD can be selected or rejected separately on each vehicle. On each vehicle, the insured can purchase a limit up to the amount of the PD liability limits. Therefore, if the insured purchases PD with a limit of $25,000, the insured has the following options for UMPD on each vehicle: 1. $10, $15, $25, Reject Coverage ii. If the insured purchases PD with a limit of $15,000, their options do not include the $25,000 limit, as follows: 1. $10, $15, Reject Coverage e. Once coverage is selected, verify usage and county if necessary. f. Click on Add New Vehicle button if multi-vehicle quote. NM Uninsured Motorists Coverage/Quoting Changes Page 3 of 11

4 Even though UM coverage was accepted on Vehicle # 1 only, the 25/50 limit applies to all vehicles on the policy including those for which it was rejected. Be sure to accept the 25/50 coverage for only one vehicle to avoid increased UM limits and higher premiums for the entire policy. Example of adding Vehicle #2. NM Uninsured Motorists Coverage/Quoting Changes Page 4 of 11

5 Example of adding Vehicle #3. Example of adding Vehicle #4. NM Uninsured Motorists Coverage/Quoting Changes Page 5 of 11

6 The Uninsured Motorists Coverage Selection /Rejection form will show what the customer selected (acceptance/rejection by vehicle and the associated price). The form will also show the limits and prices for all the options available, but were not selected. In the end, the customer is signing off to the fact that they were presented all the available options and pricing, and to the fact that they made an informed decision on which ones to buy. Click Continue button when finished with all vehicles. 5. Enter driver information. g. If they have violations, click on New Violation and enter information. h. If there are multiple drivers click on Add New Driver. i. Click Continue button. 6. Click Rate Quote. NM Uninsured Motorists Coverage/Quoting Changes Page 6 of 11

7 7. Verify quote and information. a. If needed to check for a different rate, click Requote at the top of the screen. b. If ready to submit click the Submit button at the top. 8. Answer underwriting questions; click Continue button. NM Uninsured Motorists Coverage/Quoting Changes Page 7 of 11

8 9. Verify all of the following screens and enter any missing information. NM Uninsured Motorists Coverage/Quoting Changes Page 8 of 11

9 10. Answer the final underwriting questions. Click green Rate button. 11. Scroll to the bottom of the screen and select the payment plan. Once the selection is made, click Bind Policy to bind. NM Uninsured Motorists Coverage/Quoting Changes Page 9 of 11

10 12. Select how you would like to have insured sign. Click Continue. 13. Select payment method. If insured pay-to-agent means sweep account payment, be sure you are set-up for sweeps. If insured bank draft-to-company, it is an electronic check (see example above). Enter all information. If you want to set-up reoccurring payment, check box that states use this for all future policy payments. NM Uninsured Motorists Coverage/Quoting Changes Page 10 of 11

11 14. If insured credit card or western union, enter all information and follow prompts. (Please be aware, all credit and debit card payments have a $2.95 fee.) 15. Print the Application and Rejection Form. a. The red text in the rejection form (see example to the right) is conditionally included based on the number of vehicles on the policy. b. Have your insured sign where indicated for both UMBI and UMPD selection and/or rejection. The following pages with changes highlighted include: Application Rejection Form Policy Holder Notice NM Uninsured Motorists Coverage/Quoting Changes Page 11 of 11

12 AMERICAN HALLMARK INSURANCE COMPANY OF TEXAS NEW MEXICO AUTOMOBILE APPLICATION PO Box Plano, TX, Phone: (800) Fax: (469) Producer Name Address City, State, Zip Phone Number Producer Code POLICY INFORMATION PRIOR INSURANCE INFORMATION Effective Date Expiration Date Policy Term Company Expiration Date Policy Number Policy Number APPLICANT INFORMATION SR 22 INFORMATION Named Insured SR22 Yes No Named Insured Mailing Name: City, State, Zip St. Case #: County Phone Date of Occurency: Reason for filing: DRIVER INFORMATION Driver Name DOB Sex Marital Relation Lic. # State Violation Pts SSN# ACCIDENTS / VIOLATIONS / LOSSES INFORMATION Driver # Date Description Points DISCOUNTS Percent Description Dr1 Dr2 Dr3 Dr4 Dr5 VEHICLE INFORMATION Veh # Year Make Model VIN Sym # Cyl Turbo 4WD Usage Cost New Terr. Address Address EMPLOYMENT Name Employer Street City State Zip Occupation LIENHOLDER(S) Veh Name Street City State Zip Coverages Veh # Bodily Injury Property Damage COVERAGES / LIMITS / PREMIUMS Non-Stacked UMBI UMPD Med Pay Other Than Collision Collision Towing & Labor Rental Premium Subtotal person/accident accident person/ accident accident person per occ. per occ. per occ. per occ. per veh Limits Veh #1 Veh #2 Same as Veh# 1 Same as Veh# 1 Same as Veh# 1 Premiums Veh #1 $ $ $ $ $ $ $ $ $ $ Veh #2 $ $ Included $ $ $ $ $ $ $ Custom Equipment $ Policy Fee $ Please note that this form is part of the Policy. TOTAL PREMIUM $ Page 1 of 3 (NM AHIC APP 09 11)

13 Policy Number: Insured: Agency: Producer Code: APPLICANT'S QUESTIONNAIRE Yes No Yes No Is any driver physically impaired? (If "Yes" explain). Are any members of the household 14 years or older not listed as operators? Members not listed must be excluded. (If "Yes" explain). Is there any driver newly licensed less than one year? (If "Yes" explain). Has any driver's license been suspended or revoked? (If "Yes" explain). Is any vehicle not titled to the applicants name? (If "Yes" explain). Are all vehicles principally garaged at the address listed above? (If "No" explain). Does any vehicle have existing damage? Existing damage will not be covered. (If "Yes" explain). Do we insure all vehicles in the household? (If "No" explain). Is any vehicle used for business or any type of delivery? (If "Yes" explain). Does any vehicle have sound receiving equipment costing over $500? (If "Yes" explain). Remarks: RECEIPT OF COMPLETE APPLICATION & DECLARATIONS I agree with the Company that the Application I have completed is, and will be relied upon as, part of the policy. I agree that I have received a complete copy of the Application and Declarations page, which both accurately disclose the coverages that I have selected and/or rejected. I understand that my policy is comprised of all the forms shown on the Declarations Page and that I may access these forms at any time by contacting the Company by phone, , fax, mail or online at our website link as provided below. Online: To request a mailed copy of my complete policy: By Phone: endorsements@hallmarkinsco.com Fax: Mail: PO Box Plano, TX It is strongly recommended that you review your policy to ensure you have adequate protection. Applicant's Signature X: Date: Page 2 of 3 (NM AHIC APP 09 11)

14 Policy Number: Insured: Agency: Producer Code: USE OF CREDIT DISCLOSURE (if applicable) In connection with your application for insurance coverage, we may review and use information contained in your credit report to help determine your premium or your eligibility for coverage. EXCLUSION OF NAMED DRIVER AND PARTIAL REJECTION OF COVERAGES This acknowledgement and rejection is applicable to all renewals issued by us or any affiliated insurer. However, we must provide a notice with each renewal as follows: This policy contains a named driver exclusion. You agree that none of the insurance coverages afforded by this policy shall apply while is operating your covered auto or any other motor vehicle. You further agree that this endorsement will also serve as a rejection of Uninsured Motorists and Underinsured Motorists Coverage while your covered auto or any other motor vehicle is operated by the excluded driver. Applicant's Signature X: Date: STATEMENT OF NO COMMERCIAL USE I hereby certify that the vehicle(s) insured by the policy applied for is/are not used for any commercial or business purposes. I will not use my vehicle in the course of my employment or while I am self employed. This statement is made for the purpose of directing the insurance company to issue the coverage for which I have applied and will form part of the application. Applicant's Signature X: Date: APPLICANTS AGREEMENT I agree with the Company that this application is part of the policy. I hereby authorize the Company to obtain underwriting reports for use in rating and/or underwriting the insurance for which I do hereby apply, and any renewal thereof. I hereby declare to the best of my knowledge that all the foregoing statements are true and that these are offered as an inducement to the company to issue the policy for which I am applying. I certify that I am authorized to permit the Company to obtain these underwriting reports on all drivers/vehicles listed herein. Should a underwriting report disagree with the information furnished on this application, or if other rating discrepancies be determined, I hereby consent to pay any resultant additional premium. I agree that if my premium remittance is not honored by the bank, no coverage will be bound. I also understand that any policy fee charged is fully earned and is not refundable. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I certify that as of this date I have had no claims in the past 3 years that have not been previously disclosed to this insurance company on this my application for insurance or through an ACORD loss notice. I understand that a claim means a loss that is covered under an insurance policy regardless of fault, payable under any of the coverages such as, collision, liability, Uninsured/Underinsured Motorists, and personal injury protection. I realize that a false statement would be a material misrepresentation and would jeopardize any continuation of coverages and payment of any claims made under this policy. Applicant's Signature X: Witness's Signature X: Date: Date: Statement of Producing Agent The undersigned hereby warrants and certifies that to the best of his knowledge all information contained herein is correct. The statements herein are those of the applicant who has signed this application in my presence, and is legally qualified to submit this application on behalf of the applicant. Applicant's Signature X: Date: Page 3 of 3 (NM AHIC APP 09 11)

15 Policy Number: Insured: Agency: Producer Code: UNINSURED/UNDERINSURED MOTORISTS COVERAGE SELECTION/REJECTION New Mexico Law requires that Uninsured/Underinsured Motorists Coverage be included in all policies insuring motor vehicle liability insurance coverage unless you specifically reject such coverage. Uninsured/Underinsured Motorists Coverage - Bodily Injury (UM/UIM BI) provides that if you suffer bodily injury, sickness or disease, including death, resulting from an accident with a person who does not carry liability insurance or is underinsured, and from whom you are legally entitled to recover damages, you may make a claim against your own insurance company for damages. Uninsured Motorists Coverage - Property Damage (UMPD) provides coverage if you suffer property damage resulting from an accident with a person who does not carry liability insurance or is underinsured, and from whom you are legally entitled to recover damages. Accepting or Rejecting Uninsured/Underinsured Motorists Coverage - Bodily Injury (UM/UIM BI) In accordance with New Mexico law, you are entitled to purchase coverage for each vehicle equal to your Bodily Injury Liability limits and the Company is required to provide you with those limits unless you reject that option in writing. Below are limit options and corresponding premiums available to you. Whether you reject or accept UM/UIM BI on any vehicle listed on the policy, you must initial below next to each vehicle to affirm your selection or rejection. UM/UIM BI Selection Option If rejected on all vehicles: If accepted on one vehicle: If accepted on two vehicles: If accepted on three vehicles: If accepted on four vehicles: If accepted on five vehicles: If accepted on six vehicles: Premium Disclosure for Uninsured/Underinsured Motorists Coverage - Bodily Injury Limits per Vehicle Rejected $25,000 each person / $50,000 each accident $25,000 each person / $50,000 each accident $25,000 each person / $50,000 each accident $25,000 each person / $50,000 each accident $25,000 each person / $50,000 each accident $25,000 each person / $50,000 each accident Aggregate Limits for All Vehicles Rejected $25,000 each person / $50,000 each accident $50,000 each person / $100,000 each accident $75,000 each person / $150,000 each accident $100,000 each person / $200,000 each accident $125,000 each person / $250,000 each accident $150,000 each person / $300,000 each accident UM/UIM BI Premium $0.00 $ DDD.CC $ DDD.CC $ DDD.CC $ DDD.CC $ DDD.CC $ DDD.CC Selection and Premium Charged for Uninsured/Underinsured Motorists Coverage - Bodily Injury Vehicle Number Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Reject Accept Applicant's Initial I reject UM/UIM BI coverage in its entirety on all of my vehicles. I have selected UM/UIM BI coverage on _1_ vehicle(s). As a result, the total limit of UM/UIM BI coverage available to me is $_25,000_ each person / $_50,000_ each accident. The total premium for this coverage is $_DDD.CC_. I understand that this is a single premium for a single coverage limit, which applies collectively to all, not each, of the vehicles on the policy. You should bear this feature in mind when purchasing insurance. Applicant's Signature X: Date: Accepting or Rejecting Uninsured Motorists Coverage - Property Damage (UMPD) In accordance with New Mexico law, you are entitled to purchase coverage up to your Property Damage Liability limits and the Company is required to provide you with those limits unless you reject that option in writing. Please indicate below your rejection of UMPD or your choice of UMPD limits by checking the appropriate box and initialing your selection or rejection for each vehicle listed on your policy. For UMPD Coverage, you may select different coverage limit options for each vehicle on your policy. UMPD Limit Veh # 1 Veh # 2 Veh # 3 Veh # 4 Veh # 5 Veh # 6 each accident Selection Initial Premium Selection Initial Premium SelectionInitial Premium Selection Initial Premium Selection Initial Premium Selection Initial Premium I reject UMPD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10,000 $ DD.CC $ DD.CC $ DD.CC $ DD.CC $ DD.CC $ DD.CC $15,000 $ DD.CC $ DD.CC $ DD.CC $ DD.CC $ DD.CC $ DD.CC $25,000 $ DD.CC $ DD.CC $ DD.CC $ DD.CC $ DD.CC $ DD.CC I affirm the selection(s) or rejection(s) for UMPD coverage as shown above. Applicant's Signature X: Date: Customer Acknowledgement I fully understand Uninsured/Underinsured Motorists Coverage - Bodily Injury and Uninsured Motorists Coverage - Property Damage. I understand that this selection/rejection form is part of the policy. I also understand that these selections or rejections apply to any continuation, renewal, change, or reinstatement of this policy unless I subsequently request a change in writing. I also understand that the premiums displayed above are for the initial policy term and may change for future policy terms in accordance with the company's rate changes. If you wish to change your selections, please call your agent. Applicant's Signature X: Date: Page 1 of 1 NM UM Sel/Rej 09 11

16 HALLMARK INSURANCE COMPANY P.O. Box Plano, Texas INSURED: POLICY NO: DATE OF MAILING: PRODUCER NUMBER: NOTICE OF NEW MEXICO UNINSURED MOTORISTS COVERAGE SELECTION/REJECTION (Form must be completed to avoid premium increase.) Thank you for choosing Hallmark Insurance Company for your auto insurance needs. It has come to our attention that you may not have been asked to initial, sign and date this required form at the time of your application or we may be unable to locate a record of your completed form. Therefore, we must now ask you to complete this form in order to continue your policy at the coverage levels you selected. Please complete the enclosed Uninsured Motorists Coverage Selection/Rejection Form and return it to your agent or Hallmark Insurance Company within 30 days from the above date of mailing. Please review and complete each section as follows: Selection and Premium Charged for Uninsured Motorists Coverage - Bodily Injury: initial once for each vehicle, and sign and date at the bottom of that section; and Accepting or Rejecting Uninsured Motorists Coverage - Property Damage (UMPD): initial once for each vehicle on the line next to the [x], and sign and date at the bottom of that section; and Customer Acknowledgement: sign and date If we or your agent do not receive this signed form, we will be required to increase your coverage to the maximum available Uninsured Motorists Coverage, which will result in a premium increase. Of course, if you desire to purchase additional coverage, you may always request this from your agent. Please return the completed Selection/Rejection form in one of the following ways: Return the form to your Independent Insurance Agent Mail to Hallmark Insurance Company, PO Box , Plano, TX Fax to Scan the completed form and attach it to an addressed to endorsements@hallmarkinsco.com We apologize for the inconvenience and appreciate your cooperation.