Underwritten By:
B
SECURITY NA
ATIONAL INSU
URANCE COM
MPANY (30)
TORIST COVE
ERAGE SELEC
CTION/REJEC
CTION FORM
FLORIDA UNIINSURED MOT
YOU ARE ELECTING
G NOT TO PURCHAS
SE CERTAIN VALUAB
BLE COVE
ERAGE WH
HICH
TS YOU AN
ND YOUR FAMILY
F
OR
R YOU ARE
E PURCHA
ASING UNIN
NSURED
PROTECT
MOTORIST
T LIMITS LESS
L
THAN
N YOUR BO
ODILY INJURY LIABILITY LIMIT
TS WHEN YOU
SIGN THIS
S FORM. PLEASE
P
RE
EAD CARE
EFULLY.
e provides for payment
p
of cerrtain benefits fo
or damages cau
used by ownerrs or operators of
Uninsured Mottorist Coverage
uninsured mottor vehicles bec
cause of bodilyy injury or death
h resulting therrefrom. Such benefits
b
may in
nclude paymentts for
certain medica
al expenses, los
st wages, and pain and suffering, subject to
o limitations and
d conditions co
ontained in the policy.
For the purposse of this coverrage, an uninsu
ured motor veh
hicle may includ
de a motor vehicle as to which
h the bodily injury limits
are less than your
y
damages.
quires that auto
omobile liabilityy policies includ
de Uninsured Motorist
M
Covera
age at limits eq
qual to the Bodiily Injury
Florida law req
Liability limits in
i your policy unless
u
you sele
ect a lower limitt offered by the
e company, or reject
r
Uninsure
ed Motorist entirely. If
you are interessted in selecting Uninsured Motorist
M
coverag
ge for limits lesss than your Bo
odily Injury Liab
bility limits, or are
a
rejecting this coverage
c
entire
ely, you must co
omplete and sign the approprriate option below.
If you decide to
o purchase any
y Uninsured Motorist coverag
ge you can sele
ect either Stackked Uninsured Motorist coverrage or
Non-stacked Uninsured
U
Moto
orist coverage. The cost of No
on-stacked Uniinsured Motorisst coverage is lower than the cost of
Stacked Uninssured Motorist coverage.
c
overage and yo
ou or a family member
m
who re
esides with you
u is injured by an
a
If you select Sttacked Uninsured Motorist co
uninsured mottorist, your polic
cy limits for eacch motor vehiccle listed on the
e policy may be
e added together to determine
e the total
amount that may
m be recovere
ed (stacked) fo
or all covered in
njuries. Thus, th
he limits availa
able to you wou
uld automatically change
during the policy period if you
u increase or decrease the nu
umber of motorr vehicles cove
ered under the policy.
If you select Non-stacked Un
ninsured Motoriist coverage an
nd you or a fam
mily member wh
ho resides with
h you is injured by an
ed person may not add or com
mbine the cove
erage provided as to two or more
m
motor vehiicles
uninsured mottorist, the injure
together to dettermine the limits of uninsured
d motorist insu
urance coverag
ge available, exxcept as describ
bed in subsecttion one
below. The inju
ured person is limited to the coverage
c
availa
able as to that motor vehicle he
h or she was occupying if injjured in
an accident wh
hile occupying a vehicle listed
d on the policy. Non-stacked Uninsured
U
Mottorist coverage is also subjectt to the
following limita
ations:
1.
2.
3.
n is occupying a motor vehicle
e not owned byy the injured pe
erson or a familly member who
o resides
If the injured person
with him
h or her, the injured person
n may elect the coverage on the motor vehiccle occupied an
nd the highest limits
l
of
coverrage afforded fo
or any one veh
hicle insured byy the injured pe
erson or any family member who
w resides witth him or
her. Such
S
coverage shall be excesss over Uninsured Motorist co
overage on the
e vehicle the injured person is
occup
pying.
If the named insured
d or family mem
mber who resid
des with him orr her is occupyiing a motor veh
hicle owned byy the
ed insured or a family membe
er who resides with
w him or herr, there is no co
overage if Unin
nsured Motoristt
name
coverrage was not purchased on th
his policy for that motor vehicle.
If, at the
t time of the accident the in
njured person is not occupying a motor vehicle, he or she is
i entitled to se
elect any
limits of Uninsured Motorist
M
covera
age for any one
e vehicle afford
ded by any one
e policy under which
w
he or she
e is
ed.
insure
ninsured Motoriist coverage, th
hen Uninsured Motorist coverrage will not ap
pply under this policy if
If you select Non-stacked Un
an insured perrson: (1) elects to recover Uninsured Motorisst coverage be
enefits under an
nother policy when
w
injured ass a
pedestrian or while
w
not occup
pying a motor vehicle;
v
or (2) elects
e
to recove
er excess Unin
nsured Motoristt coverage benefits
under a policy other than this
s policy in addittion to the Unin
nsured Motoristt coverage on the
t motor vehiccle he or she iss
en injured while
e occupying a motor
m
vehicle that
t
is not owne
ed by any persson insured und
der this policy.
occupying whe
49001 (02/111)
Pagge 1
Underwritten By:
B
SECURITY NA
ATIONAL INSU
URANCE COM
MPANY (30)
Your policy will
w be issued with Stacked Uninsured Motorist
M
coverage unless yo
ou select the Non-stacked
Uninsured Motorist covera
age option be
elow.
Selection/Rejection of Cove
erage Instructtions
Florida Applica
ants: If you do not want "Staccked Uninsured
d Motorist" cove
erage equal to your Bodily Injury liability limiits, you
must select on
ne of the option
ns below. You may
m select Uninsured Motorisst coverage lim
mits up to the Bo
odily Injury liab
bility limits
in your policy or
o you may reje
ect Uninsured Motorist
M
Coverrage entirely. If you do not reje
ect Uninsured Motorist Coverrage
entirely you ma
ay select "Stac
cked Uninsured
d Motorist" or "N
Non-stacked Uninsured
U
Moto
orist." If you do
o not send backk this
form, you will have
h
Stacked Uninsured
U
Moto
orist coverage equal to your Bodily
B
Injury lia
ability limits.
Your current declarations pa
Renewal/Exis
sting Florida Policyholders:
P
age reflects your previous sellection or rejecction of
Uninsured Mottorist coverage
e. Your previous selection or rejection
r
will co
ontinue to applyy to your existin
ng policy and any
a policy
that renews, exxtends, supers
sedes, or replacces your existin
ng policy unlesss you request a change to yo
our previous se
election or
rejection in wriiting. Any chan
nge to Uninsure
ed Motorist covverage will not become effecttive until the Co
ompany receives the
properly completed selection/rejection form.
Your previous selection or re
ejection also willl continue to apply to any pollicy that change
es your existing policy unlesss you
request a chan
nge to your pre
evious selection
n or rejection in
n writing. Any change
c
to Uninsured Motorist coverage will not
become effective until the Co
ompany receive
es the properlyy completed selection/rejection form.
However, if you are receiving
g this form beca
ause you changed your Bodilly Injury Liabilitty limits, then your
y
Uninsured Motorist
coverage limitss will be changed, effective ba
ack to the date
e that you changed your Bodilly Injury Liabilitty limits, to Staccked
Uninsured Mottorist coverage
e equal to your revised Bodily Injury Liability limits if you do not follow th
he above instrructions
for Florida Ap
pplicants by se
electing one of
o the options below. If you do not want Sttacked Uninsurred Motorist coverage
equal to your Bodily
B
Injury Lia
ability limits, yo
ou must follow the above instrructions for Flo
orida Applicantss.
49001 (02/111)
Pagge 2
Underwritten By:
B
SECURITY NA
ATIONAL INSU
URANCE COM
MPANY (30)
erage
Selection/Rejection of Cove
Please select one
o coverage option below and
a a limits amo
ount if listed un
nder that option
n:
ured Motorist Coverage in the
t same limitts as my Bodily Injury liability
____ I want Stacked Uninsu
coverage. (Note: If you select this option
o
the first paragraph of
o this form shall not apply.))
orist Coverage in the same limits as my Bodily
B
Injury
____ I want Non-stacked Uninsured Moto
liability co
overage.
…………………
…………………
……………………………………
…………………
……………………………………
…………………
…………
_____ I want Stacked
S
Unins
sured Motoris
st Coverage att the limits am
mount selected
d below, which
h is less than
my Bodily
y Injury liabilitty coverage limit.
____ $10,000/$20,000
____ $25,000/$50,000
____ $50,000/$100
0,000
____ $100,000/$300,000
…………………
……………………………………
…………………
……………………………………
…………………
…………
…………………
____I want No
on-stacked Un
ninsured Moto
orist Coverage
e at the limits amount selec
cted below, wh
hich is less
than my Bodily Injury liability coverrage limit.
____ $10,000/$20,000
_____
_ $25,000/$50,000
____ $50,000/$100
0,000
____ $100,000/$30
00,000
…………………
……………………………………
…………………
……………………………………
…………………
…………
…………………
____ I reject all Uninsured Motorist Coverag
ge.
I understand and
a agree that this
t
selection of
o the option ab
bove applies to my liability inssurance policy, and will also apply
a
to
any policy with
h the same Bod
dily Injury Liability limits as myy existing policy that renews, extends, changes, supersede
es, or
replaces my exxisting policy. If I decide to re
equest a chang
ge to my selecttion, the change will not become effective un
ntil the
Company rece
eives my selecttion on this form
m and it has be
een completed and signed.
____________
____________
________
Policy Numberr
____________
____________
________
Named Insured
____________
____________
________
Effective Date//Time
____________
____________
________
First Named In
nsured’s Signatture
49001 (02/111)
___
___________
Datte
____
_____
Time
e
Pagge 3