Uninsured/Underinsured Motorist Bodily Injury Form

Department of Business Regulation Insurance Division 1511 Pontiac Avenue, Bldg. 69-2 Cranston, Rhode Island 02920 Insurance Bulletin Number 2017-4 Conformance with the provisions of 230-RICR-20-05-1 Part 1.5(A) requires that a form substantially similar to the following be used to reject uninsured/underinsured motorist bodily injury coverage. PURSUANT TO § 27-7-2.1 UNINSURED/UNDERINSURED MOTORIST BODILY INJURY * REJECTION NOTICE AND WARNING * THE LAW REQUIRES YOU TO READ THIS NOTICE FOR YOUR INFORMATION In order to make sure that you are aware of the risks of going without uninsured/underinsured motorist bodily injury coverage, the State of Rhode Island requires your insurance producer or insurance company to obtain your signature showing that you have read this document and understand this warning, before they are allowed to sell you motor vehicle insurance without uninsured/underinsured motorist bodily injury coverage. IF YOU CHOOSE NOT TO BUY UNINSURED/UNDERINSURED MOTORIST BODILY INJURY COVERAGE YOU MIGHT HAVE NO MOTOR VEHICLE INSURANCE COVERAGE FOR YOUR OWN INJURIES IF YOU ARE HIT BY AN UNINSURED MOTORIST. Many motorists will ignore mandatory auto insurance laws, and many motorists passing through from another state will not have insurance. Most uninsured/underinsured motorists do not have assets or money to pay you for your injuries, even if you win a lawsuit against them. Uninsured/underinsured motorist bodily injury coverage may be your only protection. The Department of Business Regulation of the State of Rhode Island STRONGLY RECOMMENDS that most motorists obtain uninsured/underinsured motorists bodily injury coverage as part of their motor vehicle insurance package. I have read and I understand this, and I choose not to buy uninsured/underinsured motorist coverage. Name Insured #1: Name Insured #2: Policy/Binder Number and Effective Date: Signed: Signed: Date: Date: 2 *UNINSURED/UNDERINSURED MOTORIST COVERAGE MAY BE REJECTED ONLY IF MINIMUM LIABILITY LIMITS ARE REQUESTED (25/50). Elizabeth Kelleher Dwyer Superintendent of Insurance November 8, 2017