Form F.36091 - Uninsured/underinsured Limit Selection Form printable pdf download

Form F.36091 - Uninsured/underinsured Limit Selection Form

NEW JERSEY

UNINSURED/UNDERINSURED LIMIT SELECTION FORM

NAMED INSURED

POLICY NUMBER

AGENCY

UNINSURED MOTORISTS INSURANCE

Uninsured Motorists Coverage pays you for damages due to bodily injury, sickness, disease or death which you would

be entitled to recover from the owner or operator of a hit and run or uninsured motor vehicle. This coverage may be

elected at limits up to a maximum of the liability limits of your policy. Your agent will assist you in selecting the proper

limit. You may purchase this coverage only if you purchase liability coverage. I have read this statement and hereby:

I elect to purchase Uninsured Motorists Coverage at the limits selected below, which I realize are below

the limits I have selected for Liability coverage:

(Initials) ________________State Required Minimum Limits

(Initials) _______________ $750,000

(Initials) ________________$300,000

(Initials) _______________ $1,000,000

(Initials) ________________$500,000

(SIGNATURE OF NAMED INSURED)

(DATE)

UNDERINSURED MOTORISTS INSURANCE

Underinsured Motorist Coverage provides benefits if you suffer Bodily Injury from an accident in which you are entitled

to recover but the other party’s insurance limits are not high enough to fully pay you. You may purchase this coverage

at limits equal to your Uninsured Motorist Limit. Your agent will assist you in selecting the proper limit. You can buy it

only if you buy Liability and Uninsured Motorist Coverages. I have read this statement and hereby:

I elect to purchase Underinsured Motorists Coverage at the limits selected below: