obsidian-yanxin/documents/insurance/auto/state_farm_steer_clear_2016.md

type, category, person, date, source

type	category	person	date	source
financial	insurance	Yanxin Lu, Xuewei Jiang	2016-12-21	state_farm_steer_clear_2016.pdf

Page 1: Statement for Qualification for Steer Clear® Discount

Insurer:

• State Farm Mutual Automobile Insurance Company
• State Farm County Mutual Insurance Company of Texas

Field	Value
Policyholder's Name	Yanxin Lu
Qualifying Driver('s) Name(s)	Xuewei Jiang
Policy Number	329 1808-D24-53A

Steer Clear Discount Initial Requirements

1. All drivers under 25 have maintained an accident-free and moving violation-free driving record in the past three years,*
2. All drivers under 25 have completed the educational and driving log requirements in good faith, and
3. All private passenger automobiles in the household are insured with State Farm Automobile Insurance Company or State Farm County Mutual Insurance Company of Texas.**

To Maintain Steer Clear Discount

1. All drivers under 25 continue to maintain an accident-free and moving violation-free driving record.*
2. All drivers under 25 should complete Second Education material received prior to 21st birthday.

Applicant's Statement

I have met the initial requirements for the Steer Clear safe driver discount and understand that I will lose the discount if I am involved in an at-fault accident or receive a moving violation. I understand that when I reach the age of 25 I will no longer qualify for this discount.

Field	Value
Signature of Qualifying Driver	(signed)
Date	12/21/2016
Signature of Qualifying Driver (2)	—
Date (2)	—
Signature of Qualifying Driver (3)	—
Date (3)	—
Signature of Parent/Guardian/Named Insured (if qualifying driver is under age 18)	—
Date	—
Agent Name and Code	—

*In some states, certain accidents and moving violations may not disqualify you. **In some states, this requirement does not apply.

Form: 1002294 | 138728.1 08-17-2012

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Page 2: 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.

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Field	Value
Application/Policy Number	329 1808-D24-53A
Named Insured(s)	LU, YANXIN & XUEWEI JIANG
Signature	(signed)
Date	12/21/2016

Form: 1003462 TX.9 Document ID: 2002 140877 202 11-18-2014