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

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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 J 05/11 GENERAL USE/STATE SPECIFIC

UA143 B 01/03 --------------------------------------------------------
UA153 C 01/06 Alabama
UA217
UA127 D 06/01 C, P REJECTION OF UNINSURED MOTORISTS
07/05 COVERAGE
UA188 B Alaska
01/10
A1809 C, P REJECTION OF UNINSURED AND
AL8888 E 01/09 UNDERINSURED MOTORISTS
AP800 C 04/08 COVERAGE OR SELECTION OF LIMIT OF
AP804 A LIABILITY
AP803 A 12/02 CT14001202 Arizona
AP802 C
01/97 CT23000196 C, P UNINSURED AND UNDERINSURED
AP805 MOTORIST COVERAGE SELECTION
AP714 D 01/97 CT22000196 FORM (ARIZONA)
AP713 D
AP711 C 12/02 CT21001202 C, P UNINSURED AND UNDERINSURED
MOTORISTS COVERAGE SELECTION
01/96 CT24000196 FORM (SPANISH)
Arkansas
12/02 CT12001202
C, P REJECTION OF PERSONAL INJURY
12/02 CT11001202 PROTECTION COVERAGE
REJECTION OF UNINSURED AND
06/00 CT13000600 UNDERINSURED MOTORISTS
COVERAGES, AND OFFER OF
INCREASED UNINSURED LIMITS
(ARKANSAS)
California

C, P DELETION OF UM COVERAGE FROM
POLICY, SELECTION OF LOWER LIMIT
OF LIABILITY, WAIVER OF COLLISION
COVERAGE
Colorado

C, P MEDICAL PAYMENTS COVERAGE
REJECTION FORM

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

C CONNECTICUT PLAN'S COMMERCIAL
PRIVATE PASSENGER VEHICLES
(INCLUDING PRIVATE PASSENGER
TYPE VEHICLES) FORMED 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

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UM/UIM Coverage Rejection Forms

UNIFORM EDITION BUREAU CODES TITLE STATE
NUMBER DATE NUMBER

AP712 D 12/02 CT10001202 CONNECTICUT PLAN'S NAMED
AP801 NONOWNED INFORMED CONSENT
01/96 CT20000196 FORM—NOTICE TO INSUREDS
UA235 A P CONNECTICUT PLAN'S PRIVATE
A1142 C 01/10 PASSENGER INFORMED CONSENT
A1789 B 03/05 FORM—NOTICE TO INSUREDS
AL8907 C 03/05 CT PLAN'S COMMERCIAL MOTOR
UA196 A 08/13 VEHICLES (INCL. MOTOR TYPE VEH. IN
09/06 LIVERY SERVICE, VAN POOL VEHICLES
A1860 B AND DEALER TRANSPORTER PLATES)
AL8859 G 05/12 INFORMED CONSENT FORM
UA233 07/12 C, P INFORMED CONSENT FORM
UA176 C UNINSURED
UA124 B 04/08
A1790 01/09 Delaware
C, P DELAWARE MOTORISTS PROTECTION
A1790 A 01/09
03/09 ACT REQUIRED STATEMENT TO
UA179 B POLICYHOLDERS
10/14 DELAWARE PERSONAL INJURY
UA158 PROTECTION EXPLANATION OF
07/09 DEDUCTIBLE OPTIONS
07/93 C, P REJECTION OF UM COVERAGE OR
SELECTION OF HIGHER LIMIT OF
LIABILITY
C SELECTION REJECTION OF LIABILITY
AND PERSONAL INJURY PROTECTION
(PIP) COVERAGES FOR TRAILERS AND
SEMITRAILERS

Florida
C FLORIDA UNINSURED MOTORIST

COVERAGE SELECTION/REJECTION -
COMMERCIAL AUTOMOBILE
P FLORIDA UNINSURED MOTORIST
COVERAGE SELECTION/REJECTION -
PERSONAL AUTOMOBILE

Georgia
C, P IMPORTANT NOTICE - GEORGIA
C, P REJECTION OR SELECTION OF

UNINSURED MOTORISTS COVERAGE,
OFFER OF DEDUCTIBLE

Idaho
C, P REJECTION OF UNINSURED MOTORISTS

COVERAGE
Illinois

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

(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

UA152 11/92 KAIP 11 REJECTION OF UNINSURED MOTORISTS
COVERAGE AN/OR UNDERINSURED
A1303 01/82 MOTORISTS COVERAGE

GU9669 01/74 KAIP 10 Kansas
UA151 11/92 C, P KANSAS AUTOMOBILE INSURANCE
AL9731 C
AL8761 A 05/15 NF-1 P&C PLAN—UNINSURED MOTORISTS
AL8761 B (3/13) COVERAGE EXCESS LIMITS REJECTION
UA198 A (ACKNOWLEDGMENT OF COVERAGE
UA182 E 05/15 REJECTION)
UA205 B C, P KANSAS UNINSURED MOTORISTS
UA238 01/10 COVERAGE/INSURANCE
A633 B EXCESS LIMITS REJECTION
UA236 09/08 (ACKNOWLEDGMENT OF COVERAGE
UA237 REJECTION)
A632 B 06/06 P MOTORCYCLES--NOTICE OF REJECTION
UA224 B OF PERSONAL INJURY PROTECTION
01/11 BENEFITS
12/02 C NOTICE OF REJECTION OF PERSONAL
INJURY PROTECTION BENEFITS -
01/11 MOTORCYCLES

01/11 Kentucky
C, P KENTUCKY NO-FAULT REJECTION
12/02
07/13 FORM
C, P NOTICE TO POLICYHOLDERS -

KENTUCKY LAW ON UNINSURED
MOTORIST COVERAGE
C, P NOTICE TO POLICYHOLDERS -
KENTUCKY LAW ON UNINSURED
MOTORIST COVERAGE

Louisiana
C, P SELECTION OR REJECTION OF

UNINSURED/UNDERINSURED
MOTORISTS PROPERTY DAMAGE
COVERAGE
C, P UNINSURED/UNDERINSURED
MOTORIST BODILY INJURY COVERAGE
FORM

Maine
P OFFER OF UNINSURED VEHICLE

COVERAGE AND SELECTION OF LIMITS
— MOTOR VEHICLE POLICIES

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
C, P OFFER OF INCREASED LIABILITY
COVERAGE FOR CLAIMS OF FAMILY
MEMBERS AT AN ADDITIONAL
PREMIUM (NEW BUSINESS)
C, P OFFER OF INCREASED LIABILITY
COVERAGE FOR CLAIMS OF FAMILY
MEMBERS AT AN ADDITIONAL
PREMIUM (NEW BUSINESS)
C WAIVER OF PIP - COMM (MD)

Mississippi
C, P NONSTACKING UNINSURED MOTORIST

INSURANCE COVERAGE

(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

AL8789 B 05/14 C, P REJECTION OF UNINSURED MOTORISTS
UA145 A 12/15 COVERAGE
UA135 C 04/96 Montana
UA125
AP830 01/90 C, P REJECTION OF UNINSURED MOTORISTS
UA229 A COVERAGE
AP1052 06/96 AIP13580696 Nebraska
UA239 A 12/04
C, P SELECTION OF UNINSURED/
AL6616 E 03/05 UNDERINSURED MOTORISTS
UA199 COVERAGES
UA201 A 10/11 Nevada

A1810 A 10/11 C, P OFFER OF UNINSURED/UNDERINSURED
07/98 MOTORISTS COVERAGE AND MEDICAL
UA178 E 05/13 PAYMENTS COVERAGE
AP1036 UM/UIM SELECTION FORM (NV)
AP1037 02/10 New Hampshire

A1805 A 08/01 C, P REJECTION OF EXCESS UNINSURED
MOTORIST COVERAGE
06/01 AIP11850601 New Jersey
NEW JERSEY NAMED NONOWNER
07/01 AP40590701 POLICY ADVISORY POLICY
DECLARATIONS
11/09 New Mexico

C, P OFFER OF UNINSURED MOTORISTS
COVERAGE SELECTION OR REJECTION
OF LIMITS AND STACKING OPTIONS
(NEW MEXICO - COMBINED SINGLE
LIMIT)

C, P OFFER OF UNINSURED MOTORISTS
COVERAGE SELECTION OR REJECTION
OF LIMITS AND STACKING OPTIONS
(NEW MEXICO - SPLIT LIMIT)
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
Ohio

C, P OFFER OR REJECTION OF UNINSURED/
UNDERINSURED MOTORIST LIABILITY
AND SELECTION OR REJECTION OF
PROPERTY DAMAGE COVERAGE
UNINSURED MOTORISTS PROPERTY
DAMAGE COVERAGE SELECTION/
REJECTION FORM (FOR ASSIGNED RISK
USE ONLY)

C UNINSURED/UNDERINSURED
MOTORISTS COVERAGE SELECTION/
REJECTION FORM (FOR ASSIGNED RISK
USE ONLY)
Oklahoma

C, P OKLAHOMA UNINSURED MOTORIST
COVERAGE LAW

(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

UA128 B 11/09 OKLAHOMA UNINSURED MOTORIST
UA171 B COVERAGE LAW
UA171 C 07/06
Oregon
UA100 C 09/15 OAR C, P SELECTION OF LOWER LIMIT
UA106 C 836-054-000
A964 B 09/14 EXHIBIT 1 OF LIABILITY FOR UNINSURED
UA103 B 09/14 MOTORISTS COVERAGE
UA105 A 04/00 UA103B0406 C, P SELECTION OF LOWER LIMIT
04/06 UA105A0406 OF LIABILITY FOR UNINSURED
UA104 A 04/06 MOTORISTS COVERAGE

A1853 04/06 UA104A0406 Pennsylvania
UA166 B C, P AUTOMOBILE INSURANCE COVERAGE
01/10
A513 E 12/12 AND PREMIUM REDUCTION OPTIONS
C, P FIRST PARTY BENEFIT OPTIONS AND
UA222 05/07 SCDI 2006
AL8915 A PREMIUM DISCOUNTS
08/01 C, P IMPORTANT NOTICE
UA156 B 09/82
UA197 A P TORT OPTION SELECTION (STEP A)
09/11 NOTICE TO NAMED INSUREDS
UA211 03/10
UA144 G C, P UNDERINSURED MOTORIST
10/00 PROTECTION OPTIONS (STEPS D AND
UA138 A 05/13 E) - REJECTION OF UNDERINSURED
MOTORISTS PROTECTION
UA138 B 05/01
C, P UNINSURED MOTORIST PROTECTION
06/15 OPTIONS (STEPS B AND C) -
REJECTION OF UNINSURED MOTORIST
PROTECTION
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/SELECTION OF UNINSURED/
UNDERINSURED MOTORIST COVERAGE

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

P CHOICE TO EXCLUDE HOUSEHOLD
RESIDENT(S) FROM COVERAGE OF
MOTOR VEHICLE LIABILITY

C, P EXPLANATION AND OFFER OF
UNINSURED AND UNDERINSURED
MOTORIST COVERAGES
Virginia

C, P IMPORTANT NOTICE (TO ADVISE OF
THE AVAILABILITY OF MEDICAL
EXPENSE, LOSS OF INCOME AND UM
COVERAGE

C, 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

UA173 07/94 IMPORTANT NOTICE (TO ADVISE OF
THE AVAILABILITY OF MEDICAL
UA177 B 12/09 EXPENSE, LOSS OF INCOME AND UM
COVERAGE
UA175 A 07/03 C, P NOTICE/ADDITIONAL COVERAGE
UA129 06/91 AVAILABLE (OFFER OF RENTAL
REIMBURSEMENT COVERAGE)(FOR
UA162 A 06/00 WVIL130- INFORMATION SEE FACT SHEET)
UA162 B 07/15 EXCESS C, P SELECTION OF LIMITS FOR
UA218 07/01 UNINSURED/UNDERINSURED
UA218 A 07/15 FORM B- MOTORISTS COVERAGE
UA220 07/01 EXCESS
UA219 Washington
UA163 B 07/01 FORM A- C, P OFFER OF PERSONAL INJURY
UA163 C EXCESS
UA164 B 01/06 PROTECTION COVERAGE
UA164 C 07/15 UA163B0106 C, P REJECTION OF UNDERINSURED
UA220 A 01/06
UA219 A 07/15 UA163C MOTORISTS COVERAGE OR SELECTION
07/15 OF LOWER LIMIT OF LIABILITY
A1816 UA164B0106
07/15 West Virginia
A1815 FORM B C, P IMPORTANT NOTICE
C, P IMPORTANT NOTICE
UA174 FORM B- C, P IMPORTANT NOTICE FOR EXCESS/
EXCESS
UMBRELLA LINES
11/09 C, P IMPORTANT NOTICE FOR EXCESS/

11/09 UMBRELLA LINES
C, P OPTIONAL EXCESS UNINSURED
05/94
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 A)
C, P UNINSURED MOTORISTS COVERAGE
OFFER (FORM B)
C, P UNINSURED MOTORISTS COVERAGE
OFFER (FORM B)
C, P UNINSURED MOTORISTS COVERAGE
OFFER/UNDERINSURED MOTORISTS
COVERAGE OFFER (SINGLE LIMIT)
C, P UNINSURED MOTORISTS COVERAGE
OFFER/UNDERINSURED MOTORISTS
COVERAGE OFFER (SPLIT LIMITS)

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

COVERAGE

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