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10009811169417567300U7273TX1

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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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10009811169417567300X2684TX1

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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 thatI 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), andI have also been given the right to reject the Uninsured/Underinsured Motorists Coverage and have made thefollowing 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 BodilyInjury and Property Damage Liability.

I choose to include Uninsured/Underinsured Motorists Coverage for bodily injury at limits equal to mylimits for Bodily Injury Liability and I reject Uninsured/Underinsured Motorists Coverage for propertydamage.

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 thatthese bodily injury limits for Uninsured/Underinsured Motorists Coverage cannot be higher than myBodily 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 damageat the limits marked below. I understand that these limits cannot be higher than my Bodily Injury andProperty 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 InsuranceCompany, Allstate Indemnity Company, Allstate Property and Casualty Insurance Company, Allstate Fireand Casualty Insurance Company, or any affiliated insurer, unless: (1) I specifically request such a changein writing; or (2) a change in the minimum amounts of motor vehicle liability insurance coverage required toestablish financial responsibility is mandated by law.

_____________________________________________ _______________

Signature of Applicant or Named Insured Date

100098111694175

_____________________________________________Application/Policy Number

Allstate County Mutual Insurance CompanyHome Office: Irving, TexasAllstate Insurance CompanyAllstate Indemnity CompanyAllstate Property and Casualty Insurance CompanyAllstate Fire and Casualty Insurance CompanyHome Office: Northbrook, Illinois

X2684-7

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