Georgia Uninsured Motorist/medical Payments Coverage Rejection/selection Form printable pdf download

Georgia

Uninsured Motorist /Medical Payments Coverage Rejection/Selection Form

Named Insured:

Policy Number:

Insurance Company:

Date:

Uninsured Motorists Coverage

Section 33-7-11 of the Georgia Insurance Code requires that, unless rejected by any Named Insured in the policy, "No

automobile liability policy or motor vehicle liability policy shall be issued or delivered in this state to the owner of such

vehicle or shall be issued or delivered by any insurer licensed in this state upon any motor vehicle then principally

garaged or principally used in this state unless it contains an endorsement or provisions undertaking to pay the insured all

sums which said insured shall be legally entitled to recover as damages from the owner or operator of an uninsured motor

vehicle, within limits exclusive of interests and cost which at the option of the insured shall be:

A. Not less than $25,000 because of bodily injury to or death of one person in any one accident, and, subject to such

limit for one person $50,000 because of bodily injury to or death of two or more persons in any one accident, and

$25,000 because of injury to or destruction of property;

B. Not greater than the limits of liability because of bodily injury to or death of one person in any one accident and of two

or more persons in any one accident, and because of injury to or destruction of property of the insured's personal

coverage in the automobile liability policy or motor vehicle liability policy issued by the insurer to the insured."

Please indicate your selections for Uninsured Motorist Coverage below (The selection(s) that show an asterisk (*) require

he payment of an additional premium(s).):

I hereby reject Uninsured Motorist Coverage entirely.

* 25 / 50 / 25 Uninsured Motorist Limits

* 75 CSL Uninsured Motorist Limit

Limits higher than those in B. above but not to exceed the auto bodily injury and property damage liability limits of

the policy.

Split Limits _______ / _______ / _______

Combined Single Limit ______________

Limits equal to the auto bodily injury and property damage liability limits of the policy.

Uninsured Motorists Deductible Option

Georgia law requires that you select a deductible option for Uninsured Motorist Coverage. (The selection(s) that show an

asterisk (*) here will result in a reduced premium.) Indicate with an "X" in the appropriate box, the desired deductible

option. Any amount payable for damages under this coverage will be in excess of the applicable deductible option.

For Split Limits, select from the following:

No deductible applies

* $250 bodily injury each accident; $250 property damage each accident

* $500 bodily injury each accident; $500 property damage each accident

* $1,000 bodily injury each accident; $1,000 property damage each accident

For Combined Single Limit (CSL), select from the following:

No deductible applies

* $500 each accident

* $1,000 each accident

* $2,000 each accident

Medical Payments Coverage

Medical Payments Coverage is available. Please indicate your selection for Medical Payments Coverage below (The

selection(s) that show an asterisk (*) require payment of additional premium.):

I hereby reject Medical Payments Coverage.

I hereby accept Medical Payments Coverage for a limit of:

* 1,000

* $2,000

* $ 5,000

* 10,000

* $25,000

* $50,000

This selection of limits and/or rejection of coverage by any Named Insured is binding upon all insureds under the

policy.

___________________________________________________________________

_________________________

Named Insured’s Signature and Title

Date

00-AU 3574 GA (6-01)

Georgia Uninsured Motorist/medical Payments Coverage Rejection/selection Form

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