Auto Insurance Information Center

What forms are needed in the state of Connecticut?

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.

Uninsured Motorists Coverage Selection of Split Limits Informed Consent: AU CT39a 0611.pdf

If you have not previously completed and signed for the selection of Uninsured/Underinsured Motorists Bodily Injury Coverage or if you want to make changes to your current coverage, please print and complete this form.

Election of Coverage Connecticut: AU CT48 0105.pdf

If you wish to select Reparations Benefits Coverage or Medical Benefits 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

UM Coverage Selection of Split Limit.pdf
Election of Coverage Connecticut.pdf


General Information
State Forms

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