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What forms are needed in the state of Florida?

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 in the 'File Attachments' section below.

Florida (FL) law requires that automobile liability policies include Uninsured Motorist Coverage at limits equal to the Bodily Injury Liability limits in your policy unless you select a lower limit, or reject Uninsured Motorist Coverage entirely. If you have not previously completed and signed the Selection/Rejection of Uninsured Motorist Coverage FL form, or if you would like to change or reject Uninsured Motorist Coverage, please print and complete this form.

FL Uninsured Motorist Coverage (Stacked) Selection/Rejection Form and Notice of Availability: AU FL39a 0412
If the Insurer name on your Declarations Page is 21st Century Indemnity Insurance Company or 21st Century Preferred Insurance Company

Selection/Rejection of Uninsured Motorists Coverage FL and Notice of Availability: AU FL39b 0412
If the Insurer name on your Declarations Page is 21st Century North America Insurance Company

Selection/Rejection of Uninsured Motorists Coverage FL: AU FL39c 0412
If the Insurer name on your Declarations Page is 21st Century Centennial Insurance Company

Selection/Rejection of Uninsured Motorists Coverage FL and Notice of Availability: AU FL39d 0412
If the Insurer name on your Declarations Page is 21st Century Centennial Insurance Company

You also have the option to purchase, at a reduced rate, non-stacked (limited) type of Uninsured Motorist Coverage. Under this form, if injury occurs in a vehicle owned or leased by you or any family member who resides with you, this policy will apply only to the extent of coverage (if any) which applies to that vehicle in this policy. If you do not elect to purchase the non-stacked form, your policy limit(s) for each motor vehicle are added together (stacked) for all covered injuries. If you would like to elect the non-stacked form of Uninsured Motorist Coverage and if you have not rejected Uninsured Motorist Coverage, please print and complete this form.

Election of Non-Stacked Uninsured Motorist Coverage (Do not complete if you have already rejected Uninsured Motorist Coverage): AU FL50 0412

Election of Stacked or Non-Stacked Uninsured Motorist Coverage and Notice of Availability (Only available if you have Uninsured Motorists Coverage): AU FL50b 0412

FL law requires that every auto insurance policy have Personal Injury Protection Coverage (PIP). However, there are several PIP coverage options available to you to either increase your Basic PIP Coverage and increase your PIP premium, or to limit your PIP coverage and reduce your PIP premium. Depending on the Insurer name shown on your Declarations Page the options may include: 1. PIP Deductibles; 2. Exclusion of Work Loss; 3. Extended PIP; and 4. Additional PIP. If you would like to make any changes to your PIP options, please print and complete the form that corresponds to the Insurer name listed on your Declarations Page. Be sure to read each option provisions carefully to ensure that your selections are valid.

Important Coverage Notice FL Personal Injury Protection Coverage (PIP): AU FL48a 1104
If the Insurer name on your Declarations Page is 21st Century Indemnity Insurance Company or 21st Century Preferred Insurance Company

FL Personal Injury Protection Coverage (PIP): AU FL48 0910
If the Insurer name on your Declarations Page is 21st Century North America Insurance Company

FL Personal Injury Protection Coverage (PIP): AU FL48b 0910
If the Insurer name on your Declarations Page is 21st Century Centennial Insurance Company

Once completed, please mail or fax the form(s) 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

FL Uninsured Motorist Coverage (Stacked) Selection/Rejection Form and Notice of Availability AU FL39a 0412.pdf
Selection/Rejection of Uninsured Motorists Coverage FL and Notice of Availability AU FL39b 0412.pdf
Selection/Rejection of Uninsured Motorists Coverage FL AU FL39c 0412.pdf
Selection/Rejection of Uninsured Motorists Coverage FL and Notice of Availability AU FL39d 0412.pdf
Election of Non-Stacked Uninsured Motorist Coverage (Do not complete if you have rejected Uninsured Motorist Coverage) AU FL50 0412.pdf
Election of Stacked or Non-Stacked Uninsured Motorist Coverage and Notice of Availability (Only available if you have Uninsured Motorists Coverage) AU FL50b 0412.pdf
Important Coverage Notice FL Personal Injury Protection Coverage (PIP) AU FL48a 1104.pdf
FL Personal Injury Protection Coverage (PIP) AU FL48 0910.pdf
FL Personal Injury Protection Coverage (PIP) AU FL48b 0910.pdf 

Topics

General Information
Coverage
State Forms

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