UM/UIM Coverage Rejection Forms

UM/UIM Coverage Rejection Forms

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:

C. Commercial PRODUCT CODES
P. Personal

(New)Denotes change. WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PAGE UM/UIM 1 of 7

UM/UIM Coverage Rejection Forms

UNIFORM EDITION BUREAU CODES TITLE STATE
NUMBER DATE NUMBER

UA137 A 01/94 --------------------------------------------------------
UA136 H 11/04 GENERAL USE/STATE SPECIFIC

UA143 B 01/03 --------------------------------------------------------
UA153 C 01/06 Alabama

UA217 06/01 C, P REJECTION OF UNINSURED MOTORISTS
UA127 D 07/05 COVERAGE
Alaska
(New) UA188 B 01/10
C, P REJECTION OF UNINSURED AND
A1809 01/09 UNDERINSURED MOTORISTS
AL8888 E 04/08 COVERAGE OR SELECTION OF LIMIT OF
AP800 C LIABILITY (ALASKA)
AP804 A 12/02 CT14001202 Arizona
AP803 A
AP805 01/97 CT23000196 C, P UNINSURED AND UNDERINSURED
AP714 D MOTORIST COVERAGE SELECTION
AP713 D 01/97 CT22000196 FORM (ARIZONA)
AP711 C
AP712 D 01/96 CT24000196 C, P UNINSURED AND UNDERINSURED
MOTORISTS COVERAGE SELECTION
12/02 CT12001202 FORM (SPANISH)
Arkansas
12/02 CT11001202
C, P REJECTION OF PERSONAL INJURY
06/00 CT13000600 PROTECTION COVERAGE
REJECTION OF UNINSURED AND
12/02 CT10001202 UNDERINSURED MOTORISTS
COVERAGES, AND OFFER OF
INCREASED UNINSURED LIMITS
(ARKANSAS)
California

C, P ELETION OF UNINSURED MOTORISTS
COVERAGE FROM POLICY, SELECTION
OF LOWER LIMIT OF LIABILITY,
WAIVER OF COLLISION DEDUCTIBLE
Colorado

C, P REJECTION OF MEDICAL PAYMENTS
COVERAGE

C, P REJECTION OF UNINSURED MOTORISTS
COVERAGE
Connecticut

C, P CONNECTICUT PLAN'S ADDITIONAL
PERSONS INFORMED CONSENT FORM—
NOTICE TO INSUREDS

C CONNECTICUT PLAN'S COMMERCIAL
MOTOR HOMES INFORMED CONSENT
FORM—NOTICE TO INSUREDS

C CONNECTICUT PLAN'S COMMERCIAL
MOTORCYCLES INFORMED CONSENT
FORM—NOTICE TO INSUREDS
CONNECTICUT PLAN'S COMMERCIAL/
GARAGE-DEALER OR TRANSPORTER
PLATES INFORMED CONSENT FORM

P CONNECTICUT PLAN'S MOTOR HOMES
INFORMED CONSENT FORM—NOTICE
TO INSUREDS

P CONNECTICUT PLAN'S MOTORCYCLES
INFORMED CONSENT FORM—NOTICE
TO INSUREDS

C, P CONNECTICUT PLAN'S NAMED
NONOWNED INFORMED CONSENT
FORM—NOTICE TO INSUREDS

P CONNECTICUT PLAN'S PRIVATE
PASSENGER INFORMED CONSENT
FORM—NOTICE TO INSUREDS

(New)Denotes change. WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PAGE UM/UIM 2 of 7

UM/UIM Coverage Rejection Forms

UNIFORM EDITION BUREAU CODES TITLE STATE
NUMBER DATE NUMBER

AP802 C 12/02 CT21001202 C INFORMED CONSENT FORM
AP801 01/96 CT20000196 INFORMED CONSENT FORM
UA235 A 01/10
A1142 C C, P INFORMED CONSENT FORM
A1789 B 03/05 UNINSURED
AL8907 B Delaware
UA196 A 03/05
C, P DELAWARE MOTORISTS PROTECTION
AL8859 C 12/83 ACT REQUIRED STATEMENT TO
UA233 POLICYHOLDERS
UA176 C 09/06 DELAWARE PERSONAL INJURY
UA124 B PROTECTION EXPLANATION OF
10/87 DEDUCTIBLE OPTIONS
A1790
04/08 C, P REJECTION OF UNINSURED MOTORISTS
UA179 B 01/09 COVERAGE OR SELECTION OF HIGHER
LIMIT OF LIABILITY - DELAWARE
UA158 01/09
UA152 C SELECTION REJECTION OF LIABILITY
03/09 AND PERSONAL INJURY PROTECTION
A1303 (PIP) COVERAGES FOR TRAILERS AND
07/09 SEMITRAILERS
GU9669 Florida
07/93
C, P REJECTION OR SELECTION OF UM
11/92 KAIP 11 COVERAGE OR SELECTION OF LOWER
LIMITS OF UM COVERAGE
01/82 Georgia

01/74 C, P IMPORTANT NOTICE
C, P REJECTION OR SELECTION OF

UNINSURED MOTORISTS COVERAGE,
OFFER OF DEDUCTIBLE - GEORGIA

Idaho
C, P IDAHO UNINSURED MOTORIST

AND UNDERINSURED MOTORIST
DISCLOSURE STATEMENT AND
REJECTION FORM

Illinois
SELECTION OF UNINSURED MOTORIST
BODILY INJURY COVERAGE LIMITS
AND ELECTION OF UNINSURED
MOTORIST PROPERTY DAMAGE
COVERAGE

Indiana
C, P REJECTION OF UNINSURED MOTORISTS

COVERAGE AND UNDERINSURED
MOTORISTS COVERAGE OR SELECTION
OF LOWER LIMIT OF LIABILITY

Iowa
C, P REJECTION OF UNINSURED MOTORISTS

COVERAGE AN/OR UNDERINSURED
MOTORISTS COVERAGE

Kansas
C, P KANSAS AUTOMOBILE INSURANCE

PLAN—UNINSURED MOTORISTS
COVERAGE EXCESS LIMITS REJECTION
(ACKNOWLEDGMENT OF COVERAGE
REJECTION)
C, P KANSAS UNINSURED MOTORISTS
COVERAGE/INSURANCE
EXCESS LIMITS REJECTION
(ACKNOWLEDGMENT OF COVERAGE
REJECTION)
P MOTORCYCLES--NOTICE OF REJECTION
OF PERSONAL INJURY PROTECTION
BENEFITS

(New)Denotes change. WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PAGE UM/UIM 3 of 7

UM/UIM Coverage Rejection Forms

UNIFORM EDITION BUREAU CODES TITLE STATE
NUMBER DATE NUMBER

AL9731 B 09/04 NF1A 1 Kentucky
AL8761 A P&C (9-04) C, P KENTUCKY NO-FAULT REJECTION
UA198 A
UA182 E 01/10 FORM
UA205 B 09/08 C, P NOTICE TO POLICYHOLDERS -
A1796 06/06
01/05 KENTUCKY L AW ON UNINSURED
A1793 MOTORIST COVERAGE
01/05
A1794 Louisiana
A1795 01/05 C, P SELECTION OR REJECTION OF
UA238 01/05
A633 B 01/11 UNINSURED/UNDERINSURED
UA148 A 12/02 MOTORISTS PROPERTY DAMAGE
UA236 10/99 COVERAGE
UA237 01/11 C, P UNINSURED/UNDERINSURED
01/11 MOTORIST BODILY INJURY COVERAGE
FORM

Maine
P OFFER OF UNINSURED VEHICLE

COVERAGE AND SELECTION OF LIMITS
— MOTOR VEHICLE POLICIES

Maryland
P MANDATORY OFFER OF INCREASED

LIABILITY COVERAGE FOR CLAIMS
OF FAMILY MEMBERS AT AN
ADDITIONAL PREMIUM (NEW
BUSINESS), MANDATORY PERSONAL
INJURY PROTECTION WAIVER, AND
MANDATORY UNINSURED MOTOR
VEHICLE LIABILITY INSURANCE IN
THE STATE OF MARYLAND OFFERED
P MANDATORY OFFER OF INCREASED
LIABILITY COVERAGE FOR PRIVATE
PASSENGER MOTOR VEHICLE
LIABILITY INSURANCE IN THE STATE
OF MARYLAND OFFERED AT AN
ADDITIONAL PREMIUM
P MANDATORY PERSONAL INJURY
PROTECTION WAIVER FOR PRIVATE
PASSENGER MOTOR VEHICLE
LIABILITY INSURANCE IN THE STATE
OF MARYLAND
P MANDATORY UNINSURED MOTORISTS
COVERAGE WAIVER FOR PROVATE
PASSENGER MOTOR VEHICLE
LIABILITY INSURANCE IN THE STATE
OF MARYLAND
C, P NOTICE AND WAIVER OF INCREASED
LIMITS OF UNINSURED MOTORIST
COVERAGE
C NOTICE CONCERNING THE WAIVER
OF PERSONAL INJURY PROTECTION
(PIP) COVERAGE—COMMERCIAL
AUTOMOBILE LIABILITY INSURANCE
NOTICE CONCERNING WAIVER OF
INCREASED LIMITS OF UNINSURED
MOTORISTS COVERAGE — PRIVATE
PASSENGER MOTOR VEHICLE
LIABILITY INSURANCE
C, P OFFER OF INCREASED LIABILITY
COVERAGE FOR CLAIMS OF FAMILY
MEMBERS AT AN ADDITIONAL
PREMIUM (NEW BUSINESS)
C, P

(New)Denotes change. WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PAGE UM/UIM 4 of 7

UM/UIM Coverage Rejection Forms

UNIFORM EDITION BUREAU CODES TITLE STATE
NUMBER DATE NUMBER

UA149 A 02/97 OFFER OF INCREASED LIABILITY
A632 B COVERAGE FOR CLAIMS OF FAMILY
UA224 A 12/02 MEMBERS AT AN ADDITIONAL
AL8789 A 08/05 PREMIUM (NEW BUSINESS)
UA145 01/80 WAIVER OF INCREASED LIMITS OF
UA135 C UNINSU RED MOTORIST COVERAGE
UA125 12/92 PRIVATE PASSENGER MOTOR VEHICLE
AP830 LIABILITY INSURANCE MARYLAND
UA229 A 04/96 C WAIVER OF PIP - COMM (MD)
AP1052
AL6616 C 01/90 Mississippi
UA199 C, P NONSTACKING UNINSURED MOTORIST
UA201 06/96 AIP13580696
12/04 INSURANCE COVERAGE
A1810 C, P REJECTION OF UNINSURED MOTORISTS
A1810 A 03/05
COVERAGE
UA178 E 08/06 Montana

07/98 C, P REJECTION OF UNINSURED MOTORISTS
COV ERAGE - MONTANA
07/00 Nebraska

01/09 NC03400109 C, P SELECTION OF UNINSURED/
UNDERINSURED MOTORISTS
02/10 COVERAGES
Nevada
08/01
C, P OFFER OF UNINSURED/UNDERINSURED
MOTORISTS COVERAGE AND MEDICAL
PAYMENTS COVERAGE
UM/UIM SELECTION FORM (NV)
New Hampshire

C, P REJECTION OF EXCESS UNINSURED
MOTORIST COVERAGE
New Jersey
NEW JERSEY NAMED NONOWNER
POLICY ADVISORY POLICY
DECLARATIONS
New Mexico

C, P REJECTION OF UNINSURED MOTORISTS
COVERAGE OR SELECTION OF HIGHER
LIMIT OF LIABILITY AND REJECTION
OF STACKING
UNINSURED MOTORISTS COVERAGE
REJECTION FORM (FOR AUTO
ASSIGNED RISK ONLY)
New York

C, P EXPLANATION AND OFFER
OF ADDITIONAL COVERAGES:
SUPPLEMENTARY UNINSURED/
UNDERINSURED MOTORISTS (SUM)
INSURANCE
North Carolina

C, P NOTICE OF RIGHT TO PURCHASE
HIGHER LIMITS OF UNINSURED
MOTORIST/UNDERINSURED
MOTORISTS

C, P NOTICE OF RIGHT TO PURCHASE
HIGHER LIMITS OF UNINSURED
MOTORIST/UNDERINSURED
MOTORISTS
Ohio

C, P OFFER OR REJECTION OF UNINSURED/
UNDERINSURED MOTORIST LIABILITY
AND SELECTION OR REJECTION OF
PROPERTY DAMAGE COVERAGE

(New)Denotes change. WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PAGE UM/UIM 5 of 7

UM/UIM Coverage Rejection Forms

UNIFORM EDITION BUREAU CODES TITLE STATE
NUMBER DATE NUMBER

AP1036 06/01 AIP11850601 UNINSURED MOTORISTS PROPERTY
DAMAGE COVERAGE SELECTION/
AP1037 07/01 AP40590701 REJECTION FORM (FOR ASSIGNED RISK
USE ONLY)
AP1035 07/01 AIP11840701 C UNINSURED/UNDERINSURED
MOTORISTS COVERAGE SELECTION/
UA128 B 11/09 REJECTION FORM (FOR ASSIGNED RISK
A1805 11/09 USE ONLY)
UA171 B P UNINSURED/UNDERINSURED
07/06 MOTORISTS COVERAGE SELECTION/
UA100 B REJECTION FORM (FOR ASSIGNED RISK
UA106 B 04/06 UA100B0406 USE ONLY)
A964 B UA106B0406
UA105 A 04/06 Oklahoma
UA104 A UA105A0406 OKLAHOMA UNINSURED MOTORIST
UA103 B 04/00 COVERAGE LAW
A1853 04/06 C, P UNINSURED MOTORIST COVERAGE
UA166 A LAW (SINGLE LIMIT)
04/06 UA104A0406
A513 E 04/06 UA103B0406 Oregon
C, P SELECTION OF LOWER LIMIT
UA222 01/10
AL8915 A 03/95 OF LIABILITY FOR UNINSURED
MOTORISTS COVERAGE
UA156 A 05/07 SCDI 2006
Pennsylvania
UA197 A 08/01 C, P AUTOMOBILE INSURANCE COVERAGE
09/82
UA211 AND PREMIUM REDUCTION OPTIONS
03/10 C, P FIRST PARTY BENEFIT OPTIONS AND

03/10 PREMIUM DISCOUNTS
C, P IMPORTANT NOTICE
10/00 C, P REJECTION OF UNDERINSURED

MOTORIST PROTECTION -
PENNSYLVANIA
C, P REJECTION OF UNINSURED MOTORIST
PROTECTION - PENNSYLVANIA
P TORT OPTION SELECTION (STEP A)
NOTICE TO NAMED INSUREDS

Rhode Island
C, P REJECTION OF MEDICAL PAYMENTS

COVERAGE
C, P UNINSURED MOTORIST BODILY

INJURY—REJECTION NOTICE AND
WARNING

South Carolina
C, P OFFER OF ADDITIONAL UNINSURED

MOTORIST COVERAGE AND OPTIONAL
UNDERINSURED MOTORIST COVERAGE

South Dakota
P REJECTION OF SUPPLEMENTAL

INSURANCE COVERAGE
Tennessee

C, P REJECTION OF UNINSURED MOTORISTS
COVERAGE OR SELECTION OF LOWER
LIMIT OF LIABILITY
Texas

C, P REJECTION OF UNINSURED/
UNDERINSURED MOTORISTS
COVERAGE OR SELECTION OF HIGHER
LIMIT OF LIABILITY

C, P SELECTION OR REJECTION OF
PERSONAL INJURY PROTECTION
COVERAGE
Utah

P

(New)Denotes change. WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PAGE UM/UIM 6 of 7

UM/UIM Coverage Rejection Forms

UNIFORM EDITION BUREAU CODES TITLE STATE
NUMBER DATE NUMBER

UA138 A 05/01 CHOICE TO EXCLUDE HOUSEHOLD
RESIDENT(S) FROM COVERAGE OF
UA173 07/94 MOTOR VEHICLE LIABILITY

UA177 A 09/98 Virginia
UA177 B 12/09 C, P IMPORTANT NOTICE (TO ADVISE OF

UA175 A 07/03 THE AVAILABILITY OF MEDICAL
UA129 06/91 EXPENSE, LOSS OF INCOME AND UM
COVERAGE
UA162 A 06/00 WVIL130- C, P NOTICE/ADDITIONAL COVERAGE
UA218 07/01 EXCESS AVAILABLE (OFFER OF RENTAL
UA220 07/01 FORM B- REIMBURSEMENT COVERAGE)(FOR
UA219 EXCESS INFORMATION SEE FACT SHEET)
UA163 B 07/01 C, P SELECTION OF LIMITS FOR
UA164 B FORM A- UNINSURED/UNDERINSURED
A1816 01/06 EXCESS MOTORISTS COVERAGE
01/06 C, P SELECTION OF LIMITS FOR
A1815 UA163B0106 UNINSURED/UNDERINSURED
MOTORISTS COVERAGE
UA174 UA164B0106
Washington
11/09 C, P OFFER OF PERSONAL INJURY

11/09 PROTECTION COVERAGE
C, P REJECTION OF UNDERINSURED
05/94
MOTORISTS COVERAGE OR SELECTION
OF LOWER LIMIT OF LIABILITY

West Virginia
C, P IMPORTANT NOTICE
C, P IMPORTANT NOTICE FOR EXCESS/

UMBRELLA LINES
C, P OPTIONAL EXCESS UNINSURED

MOTORISTS COVERAGE OFFER (SINGLE
LIMIT)
C, P OPTIONAL EXCESS UNINSURED
MOTORISTS COVERAGE OFFER (SPLIT
LIMITS)
C, P UNINSURED MOTORISTS COVERAGE
OFFER (FORM A)
C, P UNINSURED MOTORISTS COVERAGE
OFFER (FORM B)

Wisconsin
C, P OFFER OF EXCESS UNINSURED

MOTORIST COVERAGE AND
UNDERINSURED MOTORIST COVERAGE
FOR RENEWAL POLICIES
C, P REJECTION OF EXCESS UNINSURED
MOTORIST COVERAGE AND/OR
UNDERINSURED MOTORIST COVERAGE

Wyoming
C, P REJECTION OF UNINSURED MOTORISTS

COV ERAGE - WYOMING

(New)Denotes change. WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PAGE UM/UIM 7 of 7