DC PIP Coverage Selection Form i.pdf - 21st Century Auto Insurance 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by reviewing the Personal Injury Protection (PIP) options available. You will see sections for Medical and Rehabilitation Expense Benefits, Work Loss Coverage, and Funeral Expense Benefits.
3. In the Medical and Rehabilitation Expense Benefits section, select your desired limit by checking the appropriate box next to either $50,000 or $100,000. If you choose to reject this coverage, check the rejection box.
4. Next, move to the Work Loss Coverage section. Choose between $12,000 or $24,000 by checking the corresponding box. Again, if you wish to reject this coverage, mark the rejection option.
5. Proceed to the Funeral Expense Benefits section. Select a limit of $4,000 or opt to reject this coverage by checking the appropriate box.
6. Finally, fill in your signature, date, printed name, and policy number at the bottom of the form before submitting it back to your Servicing Office.

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