1003462 TX.

8 2001 140877 201 11-07-2013

State Farm Mutual Automobile Insurance Company
State Farm Fire and Casualty Company
State Farm County Mutual Insurance Company of Texas
Texas Uninsured/Underinsured Motorists and Personal Injury Protection Coverages
(Acknowledgment of Coverage Rejection)
Uninsured/Underinsured Motorists Coverage protects the named insured, any family member of the named insured residing
in his or her household, and occupants of the insured vehicle who are legally entitled to recover damages from owners or
operators of uninsured or underinsured motor vehicles because of bodily injury or property damage caused by accident.
(The underinsured portion applies only when your damages are greater than the at-fault drivers available liability coverage.
We pay the amount that your damages exceed the at-fault drivers available liability coverage, but never more than the
amount of your 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
resulting from a motor vehicle accident. It also pays eighty percent of lost income or the reasonable expenses incurred to
replace services normally 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.
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 Uninsured/Underinsured Motorists Coverage in its entirety, and I reject
such coverage.
2. I have been given the option to reject the Property Damage Coverage portion of Uninsured/Underinsured
Motorists Coverage, and I reject such coverage.
3. I have been given the option to purchase Personal Injury Protection Coverage and I reject such coverage.
I understand and agree that:
a. there is no Uninsured/Underinsured Motorists Coverage or Personal Injury Protection Coverage on any vehicle
described in the policy that is not insured for liability coverage; and
b. this acknowledgment of coverage rejection shall be applicable to the policy of insurance for which I am applying, to all
future renewals of the policy, and to future replacement policies issued to me for any reason, including, but not limited
to, change of vehicle or coverage, an additional vehicle, or because of an interruption in coverage, until I notify the
Company, in writing, to the contrary.
Application/Policy Number
254 5126-E27-53
I hereby declare the foregoing statements to be true to the best of my knowledge and belief.
Named Insured(s) (as appearing on the application or policy)
RAMAKRISHNAVADLAPATLA, KARTHEEK
Signature of Any Named Insured (If a Business, a Company Representative should print and sign here) Date