COMMONWEALTH OF Kentucky KENTUCKY No Fault Rejection Form

COMMONWEALTH OF
KENTUCKY
Kentucky
No‐Fault Rejection Form
Department of Insurance
P. O. Box 517
Frankfort, Kentucky 40602‐0517
The Federal Administrative Procedure Act, 5 section 552a(2)(B)(b) requires any state agency which requests an
individual to disclose his social security account number to inform the individual if such disclosure is mandatory and
the statutory authority for soliciting the number. KRS 304.39‐060 requires the Department of Insurance to establish
record keeping procedures of those who elect to reject no‐fault. Rejections are effective until revoked, possibly for
a lifetime. It is therefore necessary to have an identifier which is unique and permanent to each individual rejector.
A social security account 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. Verification of no‐fault rejector status provided by the department to persons making
inquiry will not release social security account information.
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 $10,000 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 $200 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, unless you "buy‐back" the Coverage. You also will still be
required to purchase liability insurance. 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.
(d) If every member of your household rejects, you must buy Guest No‐Fault to provide Basic No‐Fault Coverage to
your passengers.
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.
NF1a 1 P&C (9‐04)
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 giving up
some rights to sue.
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 reject my No‐Fault benefits.
2. I accept my No‐Fault benefits but other members of the household want to keep their right to sue or
to be sued.
3. As to my ownership and operation of motorcycles, I want to keep my right to sue or be sued so I
reject my No‐Fault benefits.
4. I previously rejected my No‐Fault benefits and I want to cancel that rejection.
HOUSEHOLD ADDRESS
City
State
Zip
MEMBERS OF THE HOUSEHOLD
(use page NF 1c P&C (9‐04) if necessary for additional family members)
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
City, County and State of Birth:
Signature:
Maiden
Date:
If the person named in this section is a minor or under a legal disability,
the full name 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 copy to be mailed to Kentucky Department of Insurance 2. One copy to be mailed to your insurance company.
4. One copy to be kept for your records.
3. One copy to be mailed to your insurance agent.
NF 1b P&C (9‐04)
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):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
Maiden
City, County and State of Birth:
Signature:
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
Name (Type/Print):
Last
Birthdate:
Soc. Sec. No.
Option #
First
Middle
City, County and State of Birth:
Signature:
Maiden
Date:
If the person named in this section is a minor or under a legal disability,
the full name of the parent or guardian is required:
NF 1c P&C (9‐04)
Check here if continued on additional page
Indicate total number of pages