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TEXAS - PERSONAL INJURY PROTECTION COVERAGE REJECTION FORM

Pursuant to Section 1952.152 of the Texas Insurance Code, I hereby reject Personal Injury Protection Coverage.
I understand that unless I request in writing, such coverage will not be provided in or supplemental to a
reinstated insurance policy or renewal insurance policy issued by Allstate County Mutual Insurance Company,
Allstate Insurance Company, Allstate Indemnity Company, Allstate Property and Casualty Insurance Company,
Allstate Fire and Casualty Insurance Company, or any affiliated insurer.

______________________________________ ____________________
Signature of Applicant or Named Insured Date:

Application/Policy Number _________________

100098111694175

Allstate County Mutual Insurance Company

Home Office: Irving, Texas
Allstate Insurance Company
Allstate Indemnity Company
Allstate Property and Casualty Insurance Company
Allstate Fire and Casualty Insurance Company
Home Office: Northbrook, Illinois

U7273-5

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+ 10009811169417567300U7273TX1 +
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TEXAS
UNINSURED/UNDERINSURED MOTORISTS COVERAGE
SELECTION/REJECTION FORM
In accordance with the provisions of Section 1952.101, Texas Insurance Code, as amended, I acknowledge that
I have been given the opportunity to purchase Uninsured/Underinsured Motorists Coverage in amounts up to
the automobile liability coverage limits I have on the policy shown (or the policy for which I have applied), and
I have also been given the right to reject the Uninsured/Underinsured Motorists Coverage and have made the
following choice:
CHECK THE BOX NEXT TO THE OPTION YOU WISH TO SELECT.
I choose to include Uninsured/Underinsured Motorists Coverage at limits equal to my limits for Bodily
Injury and Property Damage Liability.
I choose to include Uninsured/Underinsured Motorists Coverage for bodily injury at limits equal to my
limits for Bodily Injury Liability and I reject Uninsured/Underinsured Motorists Coverage for property
damage.
I choose to include Uninsured/Underinsured Motorists Coverage for bodily injury at the limits marked
below and I reject Uninsured/Underinsured Motorists Coverage for property damage. I understand that
these bodily injury limits for Uninsured/Underinsured Motorists Coverage cannot be higher than my
Bodily Injury Liability limits nor lower than $30,000/ $60,000:
$ __________ ,000/per person $__________ ,000/per accident
I choose to include Uninsured/Underinsured Motorists Coverage for bodily injury and property damage
at the limits marked below. I understand that these limits cannot be higher than my Bodily Injury and
Property Damage Liability limits, nor lower than $30,000/$60,000/$25,000:
$ __________ ,000/per person $__________ ,000/per accident
$ __________ ,000 for property damage
I choose to reject Uninsured/Underinsured Motorists Coverage in its entirety.
I understand that this Uninsured/Underinsured Motorists Coverage selection will apply to all subsequent,
renewal, and replacement policies issued by Allstate County Mutual Insurance Company, Allstate Insurance
Company, Allstate Indemnity Company, Allstate Property and Casualty Insurance Company, Allstate Fire
and Casualty Insurance Company, or any affiliated insurer, unless: (1) I specifically request such a change
in writing; or (2) a change in the minimum amounts of motor vehicle liability insurance coverage required to
establish financial responsibility is mandated by law.
_____________________________________________ _______________
Signature of Applicant or Named Insured Date

100098111694175
_____________________________________________
Application/Policy Number

Allstate County Mutual Insurance Company

Home Office: Irving, Texas
Allstate Insurance Company
Allstate Indemnity Company
Allstate Property and Casualty Insurance Company
Allstate Fire and Casualty Insurance Company
Home Office: Northbrook, Illinois
X2684-7
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+ 10009811169417567300X2684TX1 +