Form_SCTNID_CTGRY.

XX0107FAXCRC_OTHER

Fax recipient information

To:
Fax #:
Number of pages faxed: 3
Policy Number: 978253420
Underwritten by:
Progressive American Insurance Co
Policyholder:
Wilfred Loccident
August 3, 2024
Page 1 of 1

1-561-276-7283
Insurance World of Delray
Contact your agent for personalized service.

Here are the policy documents you requested

………………………………………………………………………………………………………………………………………………………..
• UM Coverage Selection/Rejection Form
We recommend that you consult with your agent before deciding to make this change or other coverage changes.
Please sign and return the attached form and include this page for reference to process your request.
You may fax or mail this information to Progressive as indicated below.
Progressive
PO Box 6807
Cleveland, OH 44101-1807
Fax: 1-800-229-1590
Thank you for choosing Progressive.

Progressive offers several convenient service options:

• Contact your agent for personalized service and counsel when you are thinking about making changes to your policy.
• Visit agent.progressive.com 24 hours a day to view and print policy documents, quote a change to your policy, update
policy information, and view claims information. While on agent.progressive.com be sure to provide us with your e-mail
address to receive reminders about upcoming payments, transaction confirmations, and claims instructions.
• Call our Customer Service number, 1-800-876-5581, to make or confirm payments over the phone, order ID cards and
Declarations pages, and more.
Form_SCTNID_CTGRY.FL04198617_SIGNFORM

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Policy Number: 978253420

Wilfred Loccident
Page 1 of 2

FLORIDA UNINSURED MOTORIST COVERAGE SELECTION/REJECTION FORM

YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH
PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST
LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS
FORM. PLEASE READ CAREFULLY.
Description of coverage
Uninsured Motorist coverage provides for payment of certain benefits for damages caused by owners or operators of
uninsured motor vehicles because of bodily injury or death resulting therefrom. Such benefits may include payments for
certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the policy.
For the purpose of this coverage, an uninsured motor vehicle may include a motor vehicle as to which the bodily injury
limits are less than your damages.
Florida law requires that automobile liability policies include Uninsured Motorist coverage limits equal to the Bodily Injury
Liability limits in your policy unless you select a lower limit offered by the company or reject Uninsured Motorist coverage
entirely. If you are interested in selecting Uninsured Motorist coverage for a limit less than your Bodily Injury Liability limits,
or are rejecting this coverage entirely, you must complete and sign the appropriate option below.
If you decide to purchase any Uninsured Motorist coverage you can select either "Stacked Uninsured Motorist", or
"Non-stacked Uninsured Motorist." The cost of Non-stacked Uninsured Motorist coverage is lower than the cost of Stacked
Uninsured Motorist coverage.
If you select "Stacked Uninsured Motorist" and you or a family member who resides with you are injured by an uninsured
motorist, your policy limits for each motor vehicle listed on the policy may be added together to determine the total
amount that may be recovered (stacked) for all covered injuries. Thus, the limits available to you would automatically
change during the policy term if you increase or decrease the number of motor vehicles covered under the policy.
If you select "Non-stacked Uninsured Motorist" and you or a family member who resides with you are injured by an
uninsured motorist, the injured person may not add or combine the coverage provided as to two or more motor vehicles
together to determine the limits of uninsured motorist insurance coverage available, except as described in subsection one
below. The injured person is limited to the coverage available as to that motor vehicle he/she was occupying if injured in
an accident while occupying a vehicle listed on the policy. "Non-stacked Uninsured Motorist" is also subject to the
following limitations:
1. If the injured person is occupying a motor vehicle not owned by the injured person or a family member who resides with
him/her, the injured person may elect the coverage on the motor vehicle occupied and the highest limits of coverage
afforded for any one vehicle insured by the injured person or any family member who resides with him/her. Such coverage
shall be excess over Uninsured Motorist coverage on the vehicle the injured person is occupying.
2. If the named insured or family member who resides with him/her is occupying a motor vehicle or motorcycle owned by the
named insured or a family member who resides with him/her, there is no coverage if Uninsured Motorist coverage was not
purchased on this policy for that motor vehicle or motorcycle.
3. If, at the time of the accident the injured person is not occupying a motor vehicle, he or she is entitled to select any one
limit of Uninsured Motorist coverage for any one vehicle afforded by a policy under which he/she is insured.
Uninsured Motorist coverage will not apply under this policy if an insured person: (1) elects to recover Uninsured Motorist
benefits under another policy when injured as a pedestrian or while not occupying a motor vehicle; or (2) elects to recover
excess Uninsured Motorist benefits under a policy other than this policy in addition to the Uninsured Motorist coverage on
the motor vehicle he/she is occupying when injured while occupying a motor vehicle that is not owned by any person
insured under this policy.
Your policy will be issued with "Stacked Uninsured Motorist" unless you select the "Non-stacked Uninsured Motorist"
option below.
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Policy Number: 978253420

Wilfred Loccident
Page 2 of 2
Selection/Rejection of coverage
If you do not want "Stacked Uninsured Motorist" coverage equal to your Bodily Injury liability limits, you must select one of
the options below. You may select Uninsured Motorist coverage limits up to the Bodily Injury liability limits in your policy
or you may reject Uninsured Motorist coverage entirely. If you do not reject Uninsured Motorist coverage entirely you may
select "Stacked Uninsured Motorist" or "Non-stacked Uninsured Motorist."
Please select one coverage option below and a limit if listed under that option:
I want Stacked Uninsured Motorist coverage in the same limits as my Bodily Injury liability coverage.
(Note: If you select this option the first paragraph of this form shall not apply.)
I want Non-stacked Uninsured Motorist coverage in the same limits as my Bodily Injury liability
coverage.
I want Stacked Uninsured Motorist coverage at the limit selected below.
………………………………………………………………………………………………………………………………………………
$10,000/$20,000
I………………………………………………………………………………………………………………………………………………
want Non-stacked Uninsured Motorist coverage at the limit selected below.
$10,000/$20,000
I reject all Uninsured Motorist coverage.
I understand and agree that this selection of the option above applies to my liability insurance policy, and will also apply
to any renewals or replacements of such policy that are issued with the same Bodily Injury Liability limits as this policy. If I
decide to request a change to my selection, the change will not become effective until the Company receives your
selection on this form and it has been completed and signed.

Signature of named insured Date

X ………………………………………………………………………………………………………………………………………………………..

Form 8617 FL (04/19)