GEORGIA

SELECTION OR REJECTION OR CHANGE OF

UNINSURED MOTORISTS COVERAGE (UMC)

Uninsured Motorists Coverage (UMC) provides insurance for the protection of persons insured under this policy who are legally
entitled to recover damages from the owner or operator of an uninsured motor vehicle because of bodily injury or death resulting
therefrom (UMBI), or for injury to or destruction of property of the insured (UMPD). The Georgia Insurance Code permits you, the
named insured on this policy, to reject Uninsured Motorists Coverage entirely or to select UMC limits less than the limits of Bodily
Injury Liability and Property Damage which you have selected as long as the minimum UMC limits selected equal or exceed the
financial responsibility limits required in Georgia.

As of January 1, 2009, you may also select whether your Uninsured Motorists Coverage will be reduced (or 'offset) by the liability
limits available to the person at fault for causing your injuries or damages or whether your Uninsured Motorist Coverage will be
available as excess coverage applying to losses in addition to the amounts payable under the liability coverage available to the person at
fault for your damages.

So that we may be certain that your policy is properly issued, ills necessary that you indicate below, your choice of Uninsured
A'!o!orisls Coverage, dale and sign the Jhrn, in the space provided.

YOUR SELECTION(S) ARE INDICATED BELOW WITH "X"

LII The undersigned hereby rejects Uninsured Motorists Coverage. The undersigned understands and agrees that Uninsured
Motorists Coverage will not be included in the policy issued.

I request Uninsured Motorists Coverage to be in the amounts indicated below. The minimum UMC coverage which can be
written must equal Georgia's basic financial responsibility limits.

UMBI UMPI)

UMPD Deductiblefl$250 E$500 {]$l000

Unless you have rejected UMC coverage above, you must also make one of the following choices:

[j I request that my UMC coverage be reduced (or "offset") by any liability coverage available to the person at fault for my
injuries/damages.

I request that my UMC coverage be excess to any liability coverage available to the person at fault for my injuries/damages. I
J
have consulted with my agent about the increase in premium associated with this selection.

I understand my policy will be issued to reflect the options I have selected with respect to the coverage shown above.

I further understand and agree that my selection of the Uninsured Motorists Coverage (UMC) options, as shown above, shall be
applicable to all vehicles described on this policy of insurance, on all future renewals of the policy, on future policies issued me
because of change of vehicle or coverage or because of an interruption of coverage, unless I subsequently request a change of such
coverage in writing.

Signature of Policyholder Date

V-8023-77-13