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City Of Decatur <br /> UM/UIM Form <br /> -�-� <br /> '���Rp� ILL1N01S AUTO SUPPLEMENT <br /> A�iENir APP.=_.t1.'HSNEG 1\S.:R.ED <br /> �Ily O'L��_'C3tilf,�L <br /> lOM�0.\'• .41Yi JPEC3�h{�1151113f10E L0171�,i17Y . ..... EifEI.TiVE GATE <br /> cooe �eeooe �r,_r�. P:'-AH.-20t}40002-01 '�7.'0?_0<� <br /> UFJINSUREDrUNDERINSURED MOTORISTS BODILY IMJURY C�VERAGE <br /> Illinois Insurance Law requires that all automobile liability policies contain uninsured <br /> motorists and underinsured motorists bodily injury coverage in limits equal to your bodily <br /> injury liability coverage. You may reject these limi[s and select limits lower than the 6odily <br /> injury liability coverage: however you must carry a minimum of 540.60U single limit or <br /> S20.000 per persoNS4Q.000 per occurrence split limits. By purchasing higher limits,you gain <br /> valuable protection at a relatively modest increase in premium. <br /> Uninsured mosorists coveraae pays fw bodily :njury losses :c you and yaur passengers as a rosult of an <br /> acadent wi�h a driver who has no liabiliry protecLion and is legaily respansible for the injuries. This <br /> includes a hr,-and-run vehi�cle whase owner and operator can not be identified. <br /> Undennsured maorists coverace pays for bodily mjury losses to you and yrour passengers as a resuR of <br /> 3n accident wi;h a driver who has li�itiry proUection witli lim�ts that are IcrrMer than �e undennwretl <br /> motorists limits you hav? seleeted, and that p�erson is logalh� respansible for yrour injunes. Undennsured <br /> motonsts roverage is only ava�lable for limrts greater than $4�.Q+JO single limit or S29.CA0 per person <br /> 540.000 p?r oca�rrence split limits. <br /> Please �ndicate by initialing below whether you �esire co�.��ag?a: im,�s R.wer than t�e todi�y njury I�aar¢y <br /> I mits of your policy. <br /> �Initials) <br /> _ I wish to rejeet uninsurea,undennsured motonsts �a?r�e 3t iim�ts equal to my ocdiiy in;ury <br /> ��ability limits and select the followeng bwer hmi;I Chaose onel: <br /> �Initialsy Split Limit �initials) Combined Single Limit <br /> $ 20.004, 49,OOd' $ 40.00Q• <br /> - - 5�.000't�Q.0�0 ?OO.SIOC <br /> - � tOC.0IXl;30C.�JDO _ 30Q.DOQ <br /> 25C.000150C.0�0 5CO.�QC <br /> 5 $�^_5G D�4 <br /> �Vthery .UL'�ers <br /> 'These iimas do not irtdude�nderinsured motorisu co��eraAe <br /> UNIMSURED MOTORISTS PROPERTY DAMAGE COVERAGE <br /> !�ninsured motaists �operty dama�e coverage provides pro�ct�on fur property damage ca��szrJ by an <br /> uninsured m,otanst. Thus coverage is 3V3eI3b12 onfy for autos fa� wi^iich you h�rve not purchaszd coll�s�cn <br /> coverage. <br /> pnitials) <br /> I select uninsured mo:arists property damape roverage for�e�albwi�g vehi�le�;si <br /> Spec,fi�'�ear;RS ake.btodel} <br /> . __ _ _ <br /> . _. . <br /> If coverage is selected.a premium must be shown on the application <br /> Coverage is �enerally descnbe� here. OMy J�e policy pmvid�zs a xmp�ete descnpdaei of the ��aer3ges , <br /> and�e�r Iimita0ons. <br /> I understand that*.he coverage selection and imrt�aices�nd;cated here will apply to all finure policy ren�rrats. <br /> continuabo�s and changes unless I notify you otlxarvwse in writing. <br /> Applicant's Signaturz �aue <br /> ACORD 61 tL(2003103) �ACORD CORPORATI�N 1993 <br /> Arthur J.Uallagher Risk Management Services,Inc. <br /> 53 <br />