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What forms are needed in the state of Arizona?

The available forms and a brief description are listed below. You can open a .pdf version of these forms by clicking on the desired form number in the 'File Attachments' section below.

Arizona Uninsured and Underinsured Motorist Coverage Selection Forms vary by company and territory:: AU AZ39e 1004.pdf, AU AZ39f 1004.pdf, AU AZ39g 1208.pdf, AU AZ39h 1208.pdf, AU AZ39i 0712.pdf, AU AZ39j 0712.pdf, AU AZ39o 0712.pdf, AU AZ39p 0712.pdf, AU AZ39q 0712.pdf, and AU AZ39r 0712.pdf, AU AZ39k 0209.pdf, AU AZ39l 0209.pdf, AU AZ39m 0209.pdf, or AU AZ39n 0209.pdf

Your policy will provide Uninsured/Underinsured Motorist coverage in the same amount as the policy's Bodily Injury Liability Limit unless you select a lower amount or no coverage. If you have not previously completed and signed the selection/rejection of Uninsured Motorists Bodily Injury Coverage or if you want to make changes to your current coverage, please print and complete this form.

Use form AU AZ39e 1004 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Centennial Insurance Company, 21st Century Premier Insurance Company or 21st Century Indemnity Insurance Company.

Use form AU AZ39f 1004 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Preferred Insurance Company.

Use form AU AZ39g 1208 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company and you are rated in one of the following territories:

207,115-315,116, 216, 117, 317, 517, 617,120-320, 122, 322, 522, 722, 822, 23, 24, 27, 131-531, 132, 232, 133-333

Use form AU AZ39h 1208 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company and you are rated in one of the following territories:

107, 10, 118, 318-618, 219-419, 21, 125, 225, 26, 28, 29, 230, 330, 530, 630

Use form AU AZ39i 0712 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Advantage Insurance Company and you are rated in one of the following territories:

207, 215, 216, 517, 617, 122, 722, 27, 231, 431, 132, 133 - 333

Use form AU AZ39j 0712 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Advantage Insurance Company and you are rated in one of the following territories:

107, 10, 118, 518, 618, 219, 419, 21, 125, 225, 26, 28, 29, 230, 330, 630

Use form AU AZ39o 0712 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Advantage Insurance Company and you are rated in one of the following territories:

115, 116, 117, 317, 120, 822, 23, 24, 131, 531

Use form AU AZ39p 0712 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Advantage Insurance Company and you are rated in one of the following territories:

315, 220, 320, 322, 522, 331, 232

Use form AU AZ39q 0712 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Advantage Insurance Company and you are rated in one of the following territories:

418

Use form AU AZ39r 0712 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Advantage Insurance Company and you are rated in one of the following territories:

318, 319, 530

Use form AU AZ39k 0209 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company and you are rated in one of the following territories:

207, 115-315, 116, 216, 117, 317, 517, 617, 120-320, 122, 322, 522, 722, 822, 23, 24, 27, 131-531, 132, 232, 133-333

Use form AU AZ39l 0209 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company and you are rated in one of the following territories:

107, 10, 118, 318-618, 219-419, 21, 125, 225, 26, 28, 29, 230, 330, 530, 630

Use form AU AZ39m 0209 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company and you are rated in one of the following territories:

207, 115-315, 116, 216, 117, 317, 517, 617, 120-320, 122, 322, 522, 722, 822, 23, 24, 27, 131-531, 132, 232, 133-333

Use form AU AZ39n 0209 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company and you are rated in one of the following territories:

107, 10, 118, 318-618, 219-419, 21, 125, 225, 26, 28, 29, 230, 330, 530, 630

Once completed, please mail or fax the form to the address or fax number listed below.

Physical Mailing and Overnight Address:

Overnight - Correspondence
21st Century Insurance
3 Beaver Valley Rd - 4th Floor
Wilmington, DE 19803

Fax Number: 1(866) 447-2611

File Attachments

UM/UIM Coverage Selection Form AU AZ39e 1004.pdf
UM/UIM Coverage Selection Form AU AZ39f 1004.pdf
UM/UIM Coverage Selection Form AU AZ39g 1208.pdf
UM/UIM Coverage Selection Form AU AZ39h 1208.pdf
UM/UIM Coverage Selection Form AU AZ39i 0712.pdf
UM/UIM Coverage Selection Form AU AZ39j 0712.pdf
UM/UIM Coverage Selection Form AU AZ39k 0209.pdf
UM/UIM Coverage Selection Form AU AZ39l 0209.pdf
UM/UIM Coverage Selection Form AU AZ39m 0209.pdf
UM/UIM Coverage Selection Form AU AZ39n 0209.pdf
UM/UIM Coverage Selection Form AU AZ39o 0712.pdf
UM/UIM Coverage Selection Form AU AZ39p 0712.pdf
UM/UIM Coverage Selection Form AU AZ39q 0712.pdf
UM/UIM Coverage Selection Form AU AZ39r 0712.pdf

Topics

General Information
Coverage
State Forms

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