ACORD 90CA (2000/01) PLEASE COMPLETE REVERSE SIDE ©ACORD CORPORATION 1981       CALIFORNIA PERSONAL AUTO APPLICATION DATE PRODUCER APPLICANT'S NAME AND MAILING ADDRESS (Include country & ZIP+4) , NAIC CODE TELEPHONE NUMBER   CODE: SUBCODE: CO/PLAN POL#: ACCT#: AGENCY CUSTOMER ID: EFFECTIVE DATE EXPIRATION DATE   X DIRECT BILL   MAIL POLICY TO AGENT PAYMENT PLAN X   AGENCY BILL   MAIL POLICY TO APPL RESIDENCE CURRENT RESIDENCE IS      OWNED    RENTED GARAGE LOCATION IF DIFF FROM ABOVE (inc county & ZIP) YRS AT CURR ADDR PRV PREVIOUS ADDRESS (If less than 3 years) VEH # VEHICLE DESCRIPTION/USE TOTAL NUMBER OF VEHICLES IN HOUSEHOLD: VEH # YEAR MAKE, MODEL AND BODY TYPE VIN/REGISTERED STATE HP/CC DATE LEASED DATE PURCH NEW/ USED VEH # COST NEW SYMBOL AGE GRP TERR MILE 1 WAY WK/SCHL # DAYS WEEK # WKS MONTH USAGE PER- FORM MULTI- CAR CAR POOL GARA- GED ODOMETER READING EST ANN FUT MILEAGE GOVERN DRIVER DRIVER USE % (Each veh much equal 100%) CLASS VEH # PASSIVE SEAT BELT AIRBAG DRV/BOTH ANTILOCK BRKS 2/4 ANTI-THEFT DEVICES CREDITS AND SURCHARGES VEH # PASSIVE SEAT BELT AIRBAG DRV/BOTH ANTILOCK BRKS 2/4 ANTI-THEFT DEVICES CREDITS AND SURCHARGES COVERAGES/PREMIUMS COVERAGES LIMITS OF LIABILITY  VEHICLE # 1  VEHICLE # 2  VEHICLE # 3  VEHICLE # 4 SINGLE LIMIT LIABILITY (CSL)   $ EA ACCIDENT   $   $   $   $ BODILY INJURY LIABILITY $ EA PERSON $ EA ACCIDENT   $   $   $   $ PROPERTY DAMAGE LIABILITY $ EA ACCIDENT   $   $   $   $ MEDICAL PAYMENTS $ EA PERSON   $   $   $   $ CSL     $ EA ACCIDENT UNINSURED MOTORISTSBI     $ EA PERSON   $ EA ACCIDENT   $   $   $   $ PD - EA ACC     $   $   $   $   $   $   $   $ COMPREHENSIVEDED   $   $   $   $   $   $   $   $ COLLISIONDED   $   $   $   $   $   $   $   $ WAIVER OF COLLISION DEDUCTIBLE (check if applicable)   $   $   $ ACV UNLESS AMOUNT STATED   $   $   $   $   $   $   $   $ TOWING & LABOR   $   $   $   $   $   $   $   $ TRANS EXP/RENTAL RE   $             /   $             /   $             /   $             /   $   $   $   $   $   $   $   $ ADDITIONAL COVERAGES/ENDORSEMENTS (include limit, deductible, premium) POLICY FEE $ TOTAL PER VEHICLE   $   $   $   $ ESTIMATED TOTAL $ DEPOSIT $ BALANCE DUE $ RESIDENT & DRIVER INFORMATION [List all residents & dependents (licensed or not) and regular operators] # NAME (AS IT APPEARS ON LICENSE) SEX MAR STAT REL TO APPPLIC DATE OF BIRTH OCC DATE LIC STDT >100 GOOD STDT DRV TRAIN GOOD DRV MAT DRV ACC PREV CSE DATE DRIVERS LICENSE #/ LIC STATE SOCIAL SECURITY # ACCIDENTS/CONVICTIONS (Note: Your driving record is verified with the state motor vehicle department) HAS ANY DRIVER SHOWN ABOVE HAD AND ACCIDENT, REGARDLESS OF FAULT, OR BEEN CONVICTED OF A MOVING VIOLATION WITHIN THE LASTYEARS?     YES     NO IF YES, INDICATE BELOW ALSO INCLUDE COMPREHENSIVE INSURANCE LOSSES DRV # DATE OF ACCIDENT/CONVICTION DESCRIPTION OF ACCIDENT OR CONVICTION PLACE OF ACCIDENT/CONVICTION BI OR DEATH AMOUNT OF PROPERTY DAMAGE YES NO        ACORD 90CA (2000/01) ©ACORD CORPORATION 1981       VEH #   ADDL INT NAME AND ADDRESS LOAN NUMBER   LOSS PAY VEH #   ADDL INT NAME AND ADDRESS LOAN NUMBER   LOSS PAY EMPLOYMENT INFORMATION (*If less than 2 years, provide name of previous employer and previous occupation under Remarks) APPLICANT'S EMPLOYER (State nature of employment is self-employed.) ADDRESS OF EMPLOYMENT WORK PHONE NUMBER YEARS W/ CURR EMPL* YEARS W/ PREV EMPL* CO-APPLICANT'S EMPLOYER (State nature of employment is self-employed.) ADDRESS OF EMPLOYMENT WORK PHONE NUMBER YEARS W/ CURR EMPL* YEARS W/ PREV EMPL* PRIOR COVERAGE PRIOR CARRIER AND PRODUCER # YEARS W/ COMPANY PRIOR POLICY NUMBER/EXPIRATION DATE GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO 1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT? X   X   9. ANY HOUSEHOLD MEMBER IN MILITARY SERVICE? (Driver number) X   X   10. ANY DRIVERS LICENSE BEEN SUSPENDED/REVOKED? X   X   2. ANY CAR MODIFIED/SPECIAL EQUIPMENT? (Include customized vans/pickups; indicate cost) X   X   11. ANY DRIVER HAVE PHYSICAL/MENTAL IMPAIRMENT? (List driver number) X   X   3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass) X   X   12. ANY FINANCIAL RESPONSIBILITY FILING? (Driver number and date of filing) X   X   4. ANY OTHER LOSSES INCURRED (Not shown in Accident/Conviction area)? X   X   13. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY? X   X   5. ANY CAR KEPT AT SCHOOL? X   X   14. ANY COVERAGE DECLINED, CANCELLED, OR NON-RENEWED DURING LAST 3 YEARS? X   X   6. ANY CAR PARKED ON STREET? X   X   15. IS THIS BROKERED BUSINESS TO THE AGENT? X   X   7. ANY OTHER AUTO INSURANCE IN HOUSEHOLD? (Include any provided by employer) X   X   16. HAS AGENT INSPECTED VEHICLE? X   X   8. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy number) X   X   17. ANY MOTORCYCLES TO BE INSURED? (Indicate driver numbers, and provide number of years licensed to drive motorcycles) X   X