M-5501 (07/2010)
M-5501 (07/2010)
VIRGINIA UNINSURED MOTORIST SELECTION FORM
Virginia Statute § 38.2-2206 requires auto liability policies to provide Uninsured Motorist Coverage with limits not less
than minimum financial responsibility limits.
By law, the limits of Uninsured Motorist Coverage will equal the limits of liability insurance on this policy. However, if
you purchase liability limits in excess of financial responsibility limits, you may select lower limits of Uninsured Motorist
Coverage by signing and returning this form. You cannot select Uninsured Motorist Coverage limits less than minimum
financial responsibility limits or more than your liability limit of insurance.
If you have any questions or wish to change your coverage, please contact your agent. Your agent must notify us of
any changes in order for such changes to be effective.
Rejection of additional limits of Uninsured Motorist insurance by any Named Insured is binding on all insureds under
this policy.
In accordance with Virginia law, the undersigned Named Insured:
(Applicable item marked
)
Selects Uninsured Motorist Coverage at the minimum limits allowed by law:
$
Bodily Injury each person $ Property Damage each accident
$
Bodily Injury each accident
Selects Uninsured Motorist Coverage at limits which are lower than the liability limits on this policy (which are
), but are higher than the minimum limits allowed by law. The limits
selected for Uninsured Motorist Coverage are:
(Enter limits if split limits of liability apply)
$
Bodily Injury each person $ Property Damage each accident
$
Bodily Injury each accident
(Enter limit if a combined single limit of liability applies)
$
Each accident
I UNDERSTAND THAT THE OPTION I HAVE SELECTED WILL APPLY TO ALL SUBSEQUENT RENEWALS OF
COVERAGE AND TO ALL POLICIES OR ENDORSEMENTS WHICH EXTEND, CHANGE, SUPERSEDE OR REPLACE
AN EXISTING POLICY ISSUED TO THE NAMED INSURED UNLESS CHANGED IN WRITING BY ANY NAMED
INSURED.
# #
Signature of Named Insured or representative Title
# #
Date Policy Number
click to sign
signature
click to edit
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