Appendix A-Approved Form - Effective 7/1/13

Appendix A-Approved Form - Effective 7/1/13. THIS FORM TO BE USED WHEN INSURED SELECTS NON-STACKING UM COVERAGE MISSISSIPPI NON-STACKING UNINSURED MOTORIST INSURANCE Miss. Code Ann. §83-11-102 provides for an optional Non-stacking Uninsured Motorist Coverage available to an insured under an auto liability policy that covers four (4) or more vehicles. The Non-stacking Uninsured Motorist limits selected shall cover all vehicles listed in the policy and does not apply per vehicle. The selection of this Non-stacking coverage imposes a limitation on adding together or stacking of coverages. If the insured selects the Non-stacking Uninsured Motorist Policy, in the event of an accident, the total limit of uninsured motorist coverage available from the policy will be only the one limit previously selected by the insured. It is an alternative to stackable uninsured motorist coverage where the coverage limits for each vehicle may be added together or stacked to determine the total coverage available. While only one limit of uninsured motorist coverage is available from a Non-stacking Uninsured Motorist policy, other limits of uninsured motorist coverage from other policies might be available to add to the single coverage available from the Non-stacking Uninsured Motorist policy depending upon the specific circumstances. The minimum limits required under Mississippi law for Non-stacking Uninsured Motorist Coverage are four (4) times the limits required by the Mississippi Motor Vehicle Safety Responsibility Law. Therefore, the Non-stacking Uninsured Motorist Coverage limits pursuant to Miss. Code Ann. §83- 11-102 require $100,000 per person, $200,000 per accident and $100,000 for property damage. An increase to the statutory limits under this Law shall increase the minimum limits for Non-stacking Uninsured Motorist coverage accordingly. I understand the limitations imposed by the Non-stacking Uninsured Motorist policy and that such coverage is an alternative to coverage without such limitation. I further agree that acceptance of this limitation shall apply to any policy from the same insurer, including sister insurers in the same holding company, which renews the coverage, extends the coverage, or changes covered vehicles unless and until I make a written request for a change to stackable uninsured motorist coverage. Selection of Non-stacking Uninsured Motorist coverage is affirmed by your signature below. I select the following coverages at the limits shown below: € Non-stackable UM Bodily Injury and UM Property Damage at limits of per person / per accident / property damage. € Non-stackable UM Bodily Injury Coverage (No Property Coverage) at limits of per person / per accident. € Non-stackable Combined Single-limit UM Coverage (Includes Bodily Injury and Property Damage Coverage together) at the limit of per accident. Date: Policy Number (if available): Applicant Name (Print): Address: Signature of Applicant: Proposed Effective Date of Coverage: Amended Form (Effective 7/1/2013)