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What forms are needed in the state of South Dakota?

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.

South Dakota law requires that the optional coverages described below be made available to you.

  • Auto Death Benefits with a limit of $10,000 to cover you for death caused by a covered accident

  • Disability Benefits payable to you for any disability due to bodily injury caused by a covered accident that prevents you from performing the duties of your regular occupation - limit of coverage for this benefit is $60 per week if you are gainfully employed or $30 per week if you are not gainfully employed.

  • Medical Expense Benefits with a minimum limit of $2,000 for bodily injuries caused by a covered accident;

Or you may reject these coverages in writing by signing the South Dakota Auto Death and Disability Benefits Selection form. If you have not previously completed and signed the South Dakota Auto Death and Disability Benefits Selection form or if you want to make changes to your current coverage, please print and complete this form.

South Dakota Auto Death And Disability Benefits Selection Form: AU SD06 0708

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

SD Auto Death and Disability Form.pdf


General Information
State Forms

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