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What forms are needed in the state of Washington?

The available forms 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.

Underinsured Motorists Coverage Options WA: AU WA39 0107r
Use this form if the insurer listed on your declarations page is 21st Century North America Insurance Company

Underinsured Motorists Coverage Options WA: AU WA39a 0107r
Use this form if the insurer listed on your declarations page is 21st Century Centennial Insurance Company

Underinsured Motorists Coverage Options WA: AU WA39b 0107r
Use this form if the insurer listed on your declarations page is 21st Century Preferred Insurance Company

Underinsured Motorists Coverage Options WA: AU WA39c 0609r
Use this form if the insurer listed on your declarations page is 21st Century Advantage Insurance Company

Washington law requires you to purchase Underinsured Motorists Coverage (protection when you are injured or your vehicle is damaged by an underinsured motorist) with limits equal your Bodily Injury Liability Coverage limits unless you tell us, in writing that: (1) you want lower limits; (2) you want to reject a portion of the coverage; or (3) you want to reject the coverage entirely.

Personal Injury Protection Coverage Options Washington: AU WA48 0105
You may use this form to purchase Basic Personal Injury Protection (PIP) and Added Personal Injury Protection (APIP), or to reject Personal Injury Protection entirely.

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

Underinsured Motorists Coverage Options WA: AU WA39 0107r.pdf 
Underinsured Motorists Coverage Options WA: AU WA39a 0107r.pdf 
Underinsured Motorists Coverage Options WA: AU WA39b 0107r.pdf 
Underinsured Motorists Coverage Options WA: AU WA39c 0609r.pdf 
Personal Injury Protection Coverage Options WA: AU WA48 0105.pdf

Topics

General Information
Coverage
State Forms

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