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COVERED PAR1Y: City of Sunny Isles Beach AGREEMENT NO.: PK2FL1 013202609-07 AGREEMENT PERIOD: 10/01/2009 To 10/01/2010 YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORISTS LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. 'PLEASE READ CAREFULLY. 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 there from. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the Coverage Agreement. 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 coverage agreements Include Uninsured Motorist coverage at limits equal to the Bodily Injury limits in your coverage agreement unless you select a lower limit offered by the Trust, or reject Uninsured Motorist entirely. Please indicate whether you desire to entirely reject Uninsured Motorist coverage, or, whether you desire this coverage at limits lower than the Bodily Injury Liability limits of your Coverage Agreement: D. 121, I hereby reject Uninsured Motorist coverage. I hereby select the following Uninsured Motorist limits which are lower than my Bodily Injury LIability LImits: each person (enter limit if applicable): $100,000 each accident. D, c. I hereby select Uninsured Motorist coverage limits equal to my Bodily Injury LIability limits. (If you select this option disregard the bold face statement above.) a. b. ELECTION OF NON-STACKED COVERAGE (Do not complete if you have rejected Uninsured Motorist) You have the option to purchase, at a reduced rate, non-stacl<ed (limited) type of Uninsured Motorists coverage. Under this form if injury occurs in a vehicle owned or leased by you or any family member who resides with you, this Coverage Agreement will apply only to the extent of coverage (if any) which applies to that vehicle in this Coverage Agreement. If an injury occurs while occupying someone else's vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of Uninsured Motorist coverage available on anyone vehicle for which you are a Named Covered Party, covered family member, or covered resident of the Named Covered Party's household. This Coverage Agreement will not apply if you select the coverage available under any other Coverage Agreement issued to you or the Coverage Agreement of any other family member who resides with you. If you do not elect to purchase the non-stacked form, your Coverage Agreement Iimit(s) for each motor vehicle are added together (stacked) for all covered injuries. Thus, your Coverage Agreement limits would automatically change during the Coverage Agreement term if you increase or decrease the number of autos covered under the Coverage Agreement 121. I hereby elect the non-stacked form of UninSUred Motorist coverage. I understand and agree that selection of any of the above options applies to my liability Coverage Agreement and future renewals or replacements of such Coverage Agreement which are issued at the same Bodily Injury Liability limits. If I decide to select another option at some future time, I must let the Trust or my agent know in writing. Signed (Covered Party) Signed PGIT 398 (07 05) Date: (Covered Party) The brtof descrlptlcn 01 covengo conlairled In 1I11s document Is Dtklg PIO'ikIed ISIIIICICOII1modaUon cnly and Is not intOndodlo <mer or describe an Qwerage ~ mm.. For I11lInI! complet. and doIailed Inforrnatlcn .eating to the scope and limits at <Xl\'era9O. pi...... ...~ dIrecUy to lilt ~ A9-.t documents. Specimen forms are ~ upon r8QUtit Page 11