No Fault Rejection Form

COMMONWEALTH OF Kentucky KENTUCKY No-Fault Rejection Form Department Of Insurance P.O. Box 517 Frankfort, Kentucky 40602-0517 KRS 304.39-060 requires the Department of Insurance to establish record keeping procedures to track those who elect not to consent to the limitations of their tort rights and liabilities. Because such rejection is effective until revoked, it is therefore necessary to have an identifier which is unique and permanent to each individual electing to reject. A social security number is such an identifier. In today's society, names are the same or similar, and names change. Birthdate and place of birth data is being collected as an alternative identifier, however, it will not have the same reliability. The Department will not release social security numbers in response to verification requests. ADVISORY CAUTION! BEFORE SIGNING THE ATTACHED KENTUCKY NO-FAULT REJECTION FORM, READ THE FOLLOWING AS WELL AS THE REJECTION FORM CAREFULLY: 1. Kentucky law requires anyone who uses, owns, or maintains a motor vehicle in this state to have insurance. The minimum required insurance is: (a) Liability Coverage of Bodily Injury $25,000 per person/$50,000 per accident, and Property Damage $25,000 per accident, or $60,000 combined Liability Coverage. (b) Uninsured Motorist Coverage equal to the minimum Bodily Injury limits, unless you reject this in a separate writing; and (c) Basic No-Fault Coverage (often called Personal Injury Protection (PIP) or Basic Reparations Benefits (BRB)) of $10,000 per person. 2. Basic No-Fault Coverage provides prompt payment of medical expenses, lost wages up to $500 per week, replacement services and survivor's benefits due to bodily injury arising out of a motor vehicle accident. These payments are made to covered injured persons who usually include occupants of the covered vehicle and pedestrians struck by the covered vehicle. Additional amounts of No-Fault coverage may be purchased as optional coverage. 3. If you have No-Fault Coverage, your right to sue the at-fault party is limited unless your injury involves a broken bone, permanent disfigurement, medical expenses over $1,000, permanent injury, or death. With these injuries that exceed the No-Fault thresholds, you retain your right to sue for pain and suffering and expenses not included by No-Fault Coverage. 4. You may reject No-Fault Coverage and the limitations on your right to sue. If you reject: (a) Your rejection will apply to you in any motor vehicle, whether owned by you or others. There is no exception for a rejection signed as a condition of employment. The only exception is that an owner or operator of a motorcycle may file a rejection that applies only to the motorcycle. (b) Your rejection will be effective upon receipt by the Department of Insurance and it will remain effective until revoked in writing, except for rejections on behalf of minors. Upon reaching the age of majority, the rejection on behalf of the minor is no longer effective. (c) You will not be entitled to receive No-Fault Benefits. Your premium may be higher due to your rejection of No-Fault, as others will have the same right to sue you for injuries, which do not reach the No-Fault thresholds, even if they did not reject. 5. You will have to prove the other party was at fault before you can recover. Your recovery will be reduced by any degree of fault on your part. NF 1a P&C (6/26) COMMONWEALTH OF Kentucky KENTUCKY No-Fault Rejection Form Department Of Insurance P.O. Box 517 Frankfort, Kentucky 40602-0517 Acceptance of No-Fault Insurance denies each individual the right to sue a negligent motorist unless certain requirements are met. You and any member of your household can retain the right to sue by completing this form and mailing it to the Kentucky Department of Insurance. DO NOT COMPLETE THIS FORM if all members of the household want to accept benefit of the No-Fault Law in return for relinquishing some rights. Any member of the household who does not accept the No-Fault restrictions on their right to sue a negligent motorist, must complete this form and will be deemed to have read and understood the Advisory, page NF 1a. Each member of the household has a choice. The choice is designated by the following numbers, which must be placed in the blank next to each name. OPTIONS— Indicate option selection number in the blank next to your name. 1. I want to keep my right to sue or be sued so I do not consent to the limitations of my tort rights and liabilities. 2. I consent to the limitations of my tort rights and liabilities but other members of the household do not want to consent to the limitations of their tort rights and liabilities. 3. As to my ownership and operation of motorcycles, I want to keep my right to sue or be sued so I do not consent to the limitations of my tort rights and liabilities. 4. I previously refused the limitations of my tort rights and liabilities and I want to cancel that rejection and accept the limitations of my tort rights and liabilities. HOUSEHOLD ADDRESS City State Zip_______ MEMBERS OF THE HOUSEHOLD (use page NF 1c P&C (9-00) if necessary for additional family members) Name (Type/Print): Option # Last First Middle Maiden Birthdate: City, County and State of Birth: Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: Name (Type/Print): Option # Last First Middle Maiden Birthdate: City, County and State of Birth: Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: Name (Type/Print): Option # Last First Middle Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: Name (Type/Print): Option # Last First Middle Maiden Birthdate: City, County and State of Birth: Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: Check here if continued on additional page______ Indicate total number of pages _____ Note: MAILING INSTRUCTIONS 1. Original and one file stamped copy to be mailed to Kentucky Department of Insurance. 2. One file stamped copy for you to mail to your insurance company. 3. One file stamped copy to be mailed to your insurance agent. 4. One file stamped copy to be kept for your records. NF 1b P&C (6/26) COMMONWEALTH OF Kentucky KENTUCKY No-Fault Rejection Form Department Of Insurance P.O. Box 517 Frankfort, Kentucky 40602-0517 CONTINUATION OF MEMBERS OF THE HOUSEHOLD Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: ________ Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: ________ Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: ________ Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: ________ Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: Name (Type/Print): Option # Last First Middle Birthdate: City, County and State of Birth: Maiden Soc.Sec. No. Signature: Date: If the person named in this section is minor or under a legal disability, the full name and signature of the parent or guardian is required: ________ NF 1c P&C (6/26) Check here if continued on additional page ____ Indicate total number of pages _____