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What forms are needed in the state of Wisconsin?

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.

WI Medical Payments Coverage Options: AU WI48 1111

Wisconsin requires us to offer you Medical Payments Coverage. You must tell us, in writing, if you do not want this coverage.

WI Uninsured and Underinsured Motorists Coverage Selection of Limits: AU WI39 0613

Wisconsin law requires you to purchase Uninsured Motorists Coverage. The minimum limit required by Wisconsin law is $25,000 per person/$50,000 per accident for Bodily Injury Coverage. You may choose the minimum Uninsured Motorists Coverage limit or you may select a higher Uninsured Motorists Coverage limit, from the options below. Higher limits will increase your premium.

Wisconsin law requires us to offer you Underinsured Motorists Coverage. In order for you to have Underinsured Motorists Coverage you must also have Uninsured Motorists Coverage. The lowest limit that you may choose is $50,000 per person/$100,000 per accident for Bodily Injury. Higher limits will increase your premium.

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

WI Medical Payments Coverage Options: AU WI48 1111.pdf
WI Uninsured and Underinsured Motorists Coverage Selection of Limits: AU WI39 0613.pdf

Topics

General Information
Coverage
State Forms
 

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