3.0 KiB
type, category, person, date, source
| type | category | person | date | source |
|---|---|---|---|---|
| insurance document | coverage rejection acknowledgment | Lu, Yanxin & Xuewei Jiang | 2016-12-21 | state_farm_coverage_rejection_2016.jpg |
Texas Uninsured/Underinsured Motorists and Personal Injury Protection Coverages
(Acknowledgment of Coverage Rejection)
Insurer:
- State Farm Mutual Automobile Insurance Company
- State Farm Fire and Casualty Company
- State Farm County Mutual Insurance Company of Texas
Uninsured/Underinsured Motorists Coverage protects persons insured who are legally entitled to recover damages from owners or drivers of uninsured or underinsured motor vehicles because of bodily injury or property damage caused by accident. (The underinsured portion applies only when an insured person's damages are greater than the at-fault driver's available liability coverage. We pay the amount that the insured person's damages exceed the at-fault driver's available liability coverage, but never more than the amount of the insured person's covered damages or the limit of liability of this coverage.)
Personal Injury Protection Coverage pays, regardless of fault, necessary medical and funeral expenses for bodily injury caused by a motor vehicle accident. It also pays eighty percent of lost income or the reasonable expenses incurred to replace services ordinarily performed by an injured person who is not employed for the care and maintenance of the family or household while that person is unable to perform these services.
Uninsured/Underinsured Motorists Coverage and Personal Injury Protection Coverage are not available on any vehicle described in the policy that is not insured for Liability Coverage.
I acknowledge that in accordance with the laws of the State of Texas (check all that apply):
-
☐ 1. I have been given the option to reject both the bodily injury and property damage portions of Uninsured/Underinsured Motorists Coverage, and I reject such coverage. (If you check box 1, do not check box 2.)
-
☐ 2. I have been given the option to reject both the bodily injury and property damage portions of Uninsured/Underinsured Motorists Coverage, and I reject only the property damage portion of such coverage. (If you check box 2, do not check box 1.)
-
☒ 3. I have been given the option to reject Personal Injury Protection Coverage and I reject such coverage.
I understand and agree that, unless a named insured requests such coverage in writing, this Acknowledgment of Coverage Rejection shall be:
(1) binding on all persons insured under the policy; and
(2) applicable to this policy of insurance, to any reinstated policy, to any supplemental to a reinstated policy, or to any renewal policy issued by the same insurer or an affiliated insurer.
| Field | Value |
|---|---|
| Application/Policy Number | 329 1808-D24-53A |
| Named Insured(s) | LU, YANXIN & XUEWEI JIANG |
| Date | 12/21/2016 |
Signature: (signed)
Form: 1003462 TX.9 Document ID: 2002 140877 202 11-18-2014