UM/UIM Coverage Rejection Forms
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1 Forms are listed alphabetically by form title. Because of the many methods of granting coverage under the various programs in use today Specific Policies, Coverage Parts, Supplemental Endorsements, Specially Filed Programs and many others it becomes impossible to cover completely all uses for the Forms in this publication. The data provided in this index under the Product Code column cannot be complete in every respect. There has been included at least the identification provided by Bureau or regulatory source material. Users must be guided by manual provisions and the filed definition of the program being used to interpret proper form usage. The following forms apply to the Product Code(s) listed below: PRODUCT CODES C. Commercial P. Personal PAGE UM/UIM 1 of 7 WOLTERS KLUWER Customer Support:
2 GENERAL USE/STATE SPECIFIC Alabama UA137 A 01/94 C, P REJECTION OF UNINSURED MOTORISTS Alaska UA136 J 05/11 C, P REJECTION OF UNINSURED AND OR SELECTION OF LIMIT OF LIABILITY UA136 K 11/17 C, P REJECTION OF UNINSURED AND OR SELECTION OF LIMIT OF LIABILITY Arizona UA143 B 01/03 C, P UNINSURED AND UNDERINSURED MOTORIST SELECTION FORM (ARIZONA) UA153 C 01/06 C, P UNINSURED AND UNDERINSURED MOTORISTS SELECTION FORM (SPANISH) Arkansas UA217 06/01 C, P REJECTION OF PERSONAL INJURY PROTECTION UA127 D 07/05 REJECTION OF UNINSURED AND S, AND OFFER OF INCREASED UNINSURED LIMITS (ARKANSAS) California UA188 B 01/10 C, P DELETION OF UM FROM POLICY, SELECTION OF LOWER LIMIT OF LIABILITY, WAIVER OF COLLISION Colorado A /09 C, P MEDICAL PAYMENTS REJECTION FORM AL8888 E 04/08 C, P REJECTION OF UNINSURED MOTORISTS Connecticut AP800 C 12/02 CT C, P CONNECTICUT PLAN'S ADDITIONAL PERSONS INFORMED CONSENT FORM NOTICE TO INSUREDS AP804 A 01/97 CT C CONNECTICUT PLAN'S COMMERCIAL MOTOR HOMES INFORMED CONSENT AP801 01/96 CT CONNECTICUT PLAN'S COMMERCIAL MOTOR VEHICLES (INCLUDING MOTOR TYPE VEHICLE IN LIVERY SERVICE, VAN POOL VEHICLES AND DEALER TRANSPORTER PLATES) INFORMED CONSENT FORM AP803 A 01/97 CT C CONNECTICUT PLAN'S COMMERCIAL MOTORCYCLES INFORMED CONSENT AP802 C 12/02 CT C CONNECTICUT PLAN'S COMMERCIAL PRIVATE PASSENGER VEHICLES (INCLUDING PRIVATE PASSENGER TYPE VEHICLES) FORMED CONSENT PAGE UM/UIM 2 of 7 WOLTERS KLUWER Customer Support:
3 AP805 01/96 CT CONNECTICUT PLAN'S COMMERCIAL/ GARAGE-DEALER OR TRANSPORTER PLATES INFORMED CONSENT FORM AP714 D 12/02 CT P CONNECTICUT PLAN'S MOTOR HOMES INFORMED CONSENT FORM NOTICE TO INSUREDS AP713 D 12/02 CT P CONNECTICUT PLAN'S MOTORCYCLES INFORMED CONSENT FORM NOTICE TO INSUREDS AP711 C 06/00 CT C, P CONNECTICUT PLAN'S NAMED NONOWNED INFORMED CONSENT AP712 D 12/02 CT P CONNECTICUT PLAN'S PRIVATE PASSENGER INFORMED CONSENT UA235 A 01/10 C, P INFORMED CONSENT FORM UNINSURED UA235 B 10/17 C, P INFORMED CONSENT FORM UNINSURED Delaware A1142 C 03/05 C, P DELAWARE MOTORISTS PROTECTION ACT REQUIRED STATEMENT TO POLICYHOLDERS A1142 D 10/17 C, P DELAWARE MOTORISTS PROTECTION ACT REQUIRED STATEMENT TO POLICYHOLDERS A1789 B 03/05 DELAWARE PERSONAL INJURY PROTECTION EXPLANATION OF DEDUCTIBLE OPTIONS AL8907 C 08/13 C, P REJECTION OF UM OR SELECTION OF HIGHER LIMIT OF LIABILITY UA196 A 09/06 C SELECTION REJECTION OF LIABILITY AND PERSONAL INJURY PROTECTION (PIP) S FOR TRAILERS AND SEMITRAILERS Florida A1860 B 05/12 C FLORIDA UNINSURED MOTORIST SELECTION/REJECTION - COMMERCIAL AUTOMOBILE AL8859 G 07/12 P FLORIDA UNINSURED MOTORIST SELECTION/REJECTION - PERSONAL AUTOMOBILE Georgia UA233 04/08 C, P IMPORTANT NOTICE - GEORGIA UA176 C 01/09 C, P REJECTION OR SELECTION OF UNINSURED MOTORISTS, OFFER OF DEDUCTIBLE Idaho UA124 B 01/09 C, P REJECTION OF UNINSURED MOTORISTS Illinois A1790 A 10/14 SELECTION OF UNINSURED MOTORIST BODILY INJURY LIMITS AND ELECTION OF UNINSURED MOTORIST PROPERTY DAMAGE Indiana UA179 B 07/09 C, P REJECTION OF UNINSURED MOTORISTS AND UNDERINSURED PAGE UM/UIM 3 of 7 WOLTERS KLUWER Customer Support:
4 MOTORISTS OR SELECTION OF LOWER LIMIT OF LIABILITY Iowa UA158 07/93 C, P REJECTION OF UNINSURED MOTORISTS AN/OR UNDERINSURED MOTORISTS Kansas UA152 11/92 KAIP 11 C, P KANSAS AUTOMOBILE INSURANCE PLAN UNINSURED MOTORISTS EXCESS LIMITS REJECTION (ACKNOWLEDGMENT OF REJECTION) A /82 C, P KANSAS UNINSURED MOTORISTS /INSURANCE EXCESS LIMITS REJECTION (ACKNOWLEDGMENT OF REJECTION) GU /74 P MOTORCYCLES--NOTICE OF REJECTION OF PERSONAL INJURY PROTECTION BENEFITS UA151 11/92 KAIP 10 C NOTICE OF REJECTION OF PERSONAL INJURY PROTECTION BENEFITS - MOTORCYCLES Kentucky AL9731 D 12/17 NF-1 P&C (12/17) C, P KENTUCKY NO-FAULT REJECTION FORM AL8761 C 06/17 C, P NOTICE TO POLICYHOLDERS - KENTUCKY LAW ON UNINSURED MOTORIST Louisiana UA198 A 01/10 C, P SELECTION OR REJECTION OF UNINSURED/UNDERINSURED MOTORISTS PROPERTY DAMAGE UA182 E 09/08 C, P UNINSURED/UNDERINSURED MOTORIST BODILY INJURY FORM Maine UA205 B 06/06 P OFFER OF UNINSURED VEHICLE AND SELECTION OF LIMITS MOTOR VEHICLE POLICIES Maryland UA238 01/11 C, P NOTICE AND WAIVER OF INCREASED LIMITS OF UNINSURED MOTORIST A633 B 12/02 C NOTICE CONCERNING THE WAIVER OF PERSONAL INJURY PROTECTION (PIP) COMMERCIAL AUTOMOBILE LIABILITY INSURANCE UA236 01/11 C, P OFFER OF INCREASED LIABILITY FOR CLAIMS OF FAMILY MEMBERS AT AN ADDITIONAL PREMIUM (NEW BUSINESS) UA237 01/11 C, P OFFER OF INCREASED LIABILITY FOR CLAIMS OF FAMILY MEMBERS AT AN ADDITIONAL PREMIUM (NEW BUSINESS) A632 B 12/02 C WAIVER OF PIP - COMM (MD) Mississippi UA224 B 07/13 C, P NONSTACKING UNINSURED MOTORIST INSURANCE PAGE UM/UIM 4 of 7 WOLTERS KLUWER Customer Support:
5 AL8789 B 05/14 C, P REJECTION OF UNINSURED MOTORISTS Montana UA145 A 12/15 C, P REJECTION OF UNINSURED MOTORISTS Nebraska UA135 C 04/96 C, P SELECTION OF UNINSURED/ S Nevada UA125 01/90 C, P OFFER OF UNINSURED/UNDERINSURED MOTORISTS AND MEDICAL PAYMENTS AP830 06/96 AIP UM/UIM SELECTION FORM (NV) New Hampshire UA229 A 12/04 C, P REJECTION OF EXCESS UNINSURED MOTORIST New Jersey AP /05 NEW JERSEY NAMED NONOWNER POLICY ADVISORY POLICY DECLARATIONS New Mexico UA239 A 10/11 C, P OFFER OF UNINSURED MOTORISTS SELECTION OR REJECTION OF LIMITS AND STACKING OPTIONS (NEW MEXICO - COMBINED SINGLE LIMIT) AL6616 E 10/11 C, P OFFER OF UNINSURED MOTORISTS SELECTION OR REJECTION OF LIMITS AND STACKING OPTIONS (NEW MEXICO - SPLIT LIMIT) UA199 07/98 UNINSURED MOTORISTS REJECTION FORM (FOR AUTO ASSIGNED RISK ONLY) New York UA201 B 02/18 C, P EXPLANATION AND OFFER OF ADDITIONAL S: SUPPLEMENTARY UNINSURED/ (SUM) INSURANCE North Carolina A1810 A 02/10 C, P NOTICE OF RIGHT TO PURCHASE HIGHER LIMITS OF UNINSURED MOTORIST/UNDERINSURED MOTORISTS Ohio UA178 E 08/01 C, P OFFER OR REJECTION OF UNINSURED/ UNDERINSURED MOTORIST LIABILITY AND SELECTION OR REJECTION OF PROPERTY DAMAGE AP /01 AIP UNINSURED MOTORISTS PROPERTY DAMAGE SELECTION/ REJECTION FORM (FOR ASSIGNED RISK USE ONLY) AP /01 AP C UNINSURED/UNDERINSURED MOTORISTS SELECTION/ REJECTION FORM (FOR ASSIGNED RISK USE ONLY) Oklahoma A1805 A 11/09 C, P OKLAHOMA UNINSURED MOTORIST LAW PAGE UM/UIM 5 of 7 WOLTERS KLUWER Customer Support:
6 UA128 B 11/09 OKLAHOMA UNINSURED MOTORIST LAW Oregon UA171 C 09/15 OAR EXHIBIT 1 C, P SELECTION OF LOWER LIMIT OF LIABILITY FOR UNINSURED MOTORISTS Pennsylvania UA100 C 09/14 C, P AUTOMOBILE INSURANCE AND PREMIUM REDUCTION OPTIONS UA106 C 09/14 C, P FIRST PARTY BENEFIT OPTIONS AND PREMIUM DISCOUNTS A964 B 04/00 C, P IMPORTANT NOTICE UA103 B 04/06 UA103B0406 P TORT OPTION SELECTION (STEP A) NOTICE TO NAMED INSUREDS UA105 A 04/06 UA105A0406 C, P UNDERINSURED MOTORIST PROTECTION OPTIONS (STEPS D AND E) - REJECTION OF UNDERINSURED MOTORISTS PROTECTION UA104 A 04/06 UA104A0406 C, P UNINSURED MOTORIST PROTECTION OPTIONS (STEPS B AND C) - REJECTION OF UNINSURED MOTORIST PROTECTION Rhode Island A /10 C, P REJECTION OF MEDICAL PAYMENTS UA166 B 12/12 C, P UNINSURED MOTORIST BODILY INJURY REJECTION NOTICE AND WARNING South Carolina A513 E 05/07 SCDI 2006 C, P OFFER OF ADDITIONAL UNINSURED MOTORIST AND OPTIONAL UNDERINSURED MOTORIST South Dakota UA222 08/01 P REJECTION OF SUPPLEMENTAL INSURANCE Tennessee AL8915 A 09/82 C, P REJECTION OF UNINSURED MOTORISTS OR SELECTION OF LOWER LIMIT OF LIABILITY Texas UA156 B 09/11 C, P REJECTION/SELECTION OF UNINSURED/ UNDERINSURED MOTORIST UA197 A 03/10 C, P SELECTION OR REJECTION OF PERSONAL INJURY PROTECTION Utah UA211 10/00 P CHOICE TO EXCLUDE HOUSEHOLD RESIDENT(S) FROM OF MOTOR VEHICLE LIABILITY UA144 G 05/13 C, P EXPLANATION AND OFFER OF UNINSURED AND UNDERINSURED MOTORIST S Virginia UA138 B 06/15 C, P IMPORTANT NOTICE (TO ADVISE OF THE AVAILABILITY OF MEDICAL EXPENSE, LOSS OF INCOME AND UM UA138 C 07/16 C, P IMPORTANT NOTICE (TO ADVISE OF THE AVAILABILITY OF MEDICAL EXPENSE, LOSS OF INCOME AND UM PAGE UM/UIM 6 of 7 WOLTERS KLUWER Customer Support:
7 UA173 07/94 C, P NOTICE/ADDITIONAL AVAILABLE (OFFER OF RENTAL REIMBURSEMENT )(FOR INFORMATION SEE FACT SHEET) UA177 B 12/09 C, P SELECTION OF LIMITS FOR UNINSURED/UNDERINSURED MOTORISTS Washington UA175 A 07/03 C, P OFFER OF PERSONAL INJURY PROTECTION UA129 A 11/16 C, P REJECTION OF UNDERINSURED MOTORISTS OR SELECTION OF LOWER LIMIT OF LIABILITY West Virginia UA162 B 07/15 C, P IMPORTANT NOTICE UA218 A 07/15 C, P IMPORTANT NOTICE FOR EXCESS/ UMBRELLA LINES UA163 C 07/15 UA163C C, P UNINSURED MOTORISTS OFFER (FORM A) UA164 C 07/15 FORM B C, P UNINSURED MOTORISTS OFFER (FORM B) UA220 A 07/15 FORM B- EXCESS C, P UNINSURED MOTORISTS OFFER/ OFFER (SINGLE LIMIT) UA219 A 07/15 C, P UNINSURED MOTORISTS OFFER/ OFFER (SPLIT LIMITS) Wisconsin A1816 A 11/11 C, P OFFER OF EXCESS UNINSURED MOTORIST AND UNDERINSURED MOTORIST FOR RENEWAL POLICIES A /09 C, P REJECTION OF EXCESS UNINSURED MOTORIST AND/OR UNDERINSURED MOTORIST Wyoming UA174 05/94 C, P REJECTION OF UNINSURED MOTORISTS PAGE UM/UIM 7 of 7 WOLTERS KLUWER Customer Support:
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