PERSONAL INJURY PROTECTION REJECTION
I understand and hereby reject the Personal Injury Protection Coverage as provided for by Article 5.06-3 of the Texas Insurance Code.
I understand that this rejection also applies to all future renewals of by automobile insurance policy.  I also understand that I may
have this coverage added to my policy at any future date.
X_______________________________  Date: ________  X__________________________________________________________________  Date: _________
 VEH #1 (Signature of Applicant)                   (Signature of Parent or Legal Guardian if Applicant is under 18 years of age.)
X_______________________________  Date: ________  X__________________________________________________________________  Date: _________
 VEH #2 (Signature of Applicant)                   (Signature of Parent or Legal Guardian if Applicant is under 18 years of age.)