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What forms are needed in the state of New York?

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.

Selection of Personal Injury Protection Coverage New York:

New York law requires that you purchase Basic Personal Injury Protection (PIP). In addition to the required Basic Personal Injury Protection, several additional options are available to you such as Optional Basic Economic Loss (OBEL), Additional Personal Injury Protection or a Personal Injury Protection Deductible. If you have not previously completed and signed the Selection of Personal Injury Protection Coverage New York or if you want to make changes to your current coverage, please print and complete this form.

AU NY48a 0814 - for customers in 21st Century Advantage Insurance Company (36)

AU NY48b 1204 - for customers in 21st Century Premier Insurance Company (55)

AU NY48c 0814 - for customers in 21st Century Preferred Insurance Company (57)

AU NY48d 0814 - for customers in 21st Century North America Insurance Company (35)

AU NY48e 0814 - for customers in 21st Century Indemnity Insurance Company (56)

AU NY48f 0711 - for customers in 21st Century National Insurance Company (89)

AU NY48g 0814 - for customers in 21st Century Security Insurance Company (8)

UM/SUM Explanatory Notice:

New York law requires that you purchase either Statutory Uninsured Motorists Coverage or Supplementary Uninsured/Underinsured Motorists Coverage (SUM). This form provides an explanation of the notable differences between these coverages as well as the option to select your desired coverage. If you have not previously completed and signed the UM/SUM Explanatory Notice or if you want to make changes to your current coverage, please print and complete this form.

AU NY39a 0506 - for customers in 21st Century North America Insurance Company (35) and 21st Century Indemnity Insurance Company (56)

AU NY39b 0506 - for customers in 21st Century Premier Insurance Company (55) and 21st Century Preferred Insurance Company (57)

AU NY39c 0907 - for customers in 21st Century Advantage Insurance Company (36)

AU NY39d 0711 - for customers in 21st Century National Insurance Company (89)

AU NY39e 0711 - for customers in 21st Century Security Insurance Company (8)

Supplemental Spousal Liability Coverage: SSL-NY (9/05)

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

Selection of PIP Coverage AU NY48a
Selection of PIP Coverage AU NY48b
Selection of PIP Coverage AU NY48c
Selection of PIP Coverage AU NY48d
Selection of PIP Coverage AU NY48e
Selection of PIP Coverage AU NY48f
Selection of PIP Coverage AU NY48g
Supplemental Spousal Liability.pdf
UM/SUM - AU NY39a 0506.pdf
UM/SUM - AU NY39b 0506 .pdf
UM/SUM - AU NY39c 0907.pdf
UM/SUM - AU NY39d 0711.pdf
UM/SUM - AU NY39e 0711.pdf
 

Topics

General Information
Coverage
State Forms
 

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