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What forms are needed in the state of Arkansas?

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.

Arkansas Personal Injury Protection Selection/Rejection of Coverage: AU AR35 0209.pdf
Use form AU AR35 0209 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company.

Arkansas law requires every automobile liability insurance policy to provide minimum medical and hospital benefits, income disability, and accidental death benefits without regard to fault, unless you reject the coverage, in writing. If you have not previously completed and signed the selection/rejection of Personal Injury Protection Coverage or if you want to make changes to your current coverage, please print and complete this form.

Arkansas Personal Injury Protection Selection/Rejection of Coverage: AU AR35a 0209.pdf
Use form AU AR35a 0209 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Centennial Insurance Company.

Arkansas law requires every automobile liability insurance policy to provide minimum medical and hospital benefits, income disability, and accidental death benefits without regard to fault, unless you reject the coverage, in writing. If you have not previously completed and signed the selection/rejection of Personal Injury Protection Coverage or if you want to make changes to your current coverage, please print and complete this form.

Arkansas Uninsured And Underinsured Motorists Coverage Selection/Rejection of Limits: AU AR39 0605.pdf
Arkansas law requires that your auto liability policy provide you with Uninsured Motorists Bodily Injury coverage equal to the Bodily Injury Liability limits that are listed on your Declarations page unless you reject these higher limits and either select a lower limit or reject this coverage entirely. If you have not previously completed and signed the selection/rejection of Uninsured And Underinsured Motorists Coverage or if you want to make changes to your current coverage, please print and complete this form.

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

Arkansas Personal Injury Protection Selection/Rejection of Coverage: AU AR35 0209.pdf
Arkansas Personal Injury Protection Selection/Rejection of Coverage: AU AR35a 0209.pdf
Arkansas Uninsured And Underinsured Motorists Coverage Selection/Rejection of Limits: AU AR39 0605.pdf

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General Information
Coverage
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