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
REMARKS
ATTACHMENTS
STATE SUPPLEMENT
MEDICAL STATEMENT
YOUNG DRIVER QUESTIONNAIRE
MOTOR VEHICLE REPORT
DRIVER TRAINING CERTIFICATE
PHOTOGRAPH
GOOD STUDENT CERTIFICATE
BILL OF SALE
FOR COMPANY USE ONLY:
ANTI-THEFT CERTIFICATE
BINDER/SIGNATURE
INSURANCE BINDER
IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:
THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THIS INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE COMPANY.
THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLCY CONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY.
IF THIS BINDER IS NOT REPLACED BY A POLICY, THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPNAY. THE QUOTED PREMIUM IS SUBJECT OT VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY.
EFFECTIVE DATE
EXPIRATION DATE
TIME
12:01 AM
NOON
COVERAGE IS NOT BOUND
NOTICE OF INSURANCE INFORMATION PRACTICES
PERSONAL INFORMATION ABOUT YOU , INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONAS OTHER THAN YOU. SUCH INFORMAITON AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOU RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
IN ADDITION, ANY PERSON WHO KOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING. IN ADDITION, IF THE AUTO PLAN OR COMPANY DESIGNATED IN THIS APPLICATION IS NON-STANDARD, I CERTIFY THAT I UNDERSTAND THE RATES FOR THIS COVERAGE ARE HIGHER THAN NORMAL, AND THAT THEY ARE ACCEPTABLE TO ME AS I HAVE BEEN UNABLE TO OBTAIN COVERAE DESIRED THROUGH THE NORMAL INSURANCE MARKET.
COPY OF THE NOTICED OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT.
PRODUCERS'S STATEMENT: I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT THE SIGNATURE OF THE
APPLICANT IS THE PERSONAL SIGNATURE OF THE APPLICANT.
HOW LONG HAVE YOU
KNOWN THE APPLICANT?
AN INSURER WHICH REFUSES TO PROVIDE COVERAGE TO AN APPLICANT WHO IS A "GOOD DRIVER" MUST PROVIDE THE APPLICANT WITH WRITTEN STATEMENT OF THE REASONS IT DENIED COVERAGE. IN GENERAL, UNDER CALIFORNIA LAW A GOOD DRIVER IS A PERSON WHO HAS NOT HAD MORE THAN ONE VIOLATION POINT OR MORE THAN ONE AT-FAULT ACCIDENT RESULTING IN ONLY PROPERTY DAMAGE IN THE LAST THREE YEARS.
I UNDERSTAND AND ACKOWLEDGE THAT UNINSURED MOTORISTS BODILY INJURY COVERAGE (UMBI) HAS BEEN OFFERED TO ME, AND THAT I HAVE THE OPTIONS OF SELECTING EITHER UMBI LIMITS LOWER THAN MY BODILY INJURY LIABILITY LIMITS, OR REJECTING UMBI COVERAGE ENTIRELY. IF I HAVE REJECTED UMBI COVERAGE OR SELECTED UMBI LIMITS LOWER THAN MY BODILY INJURY LIABILITY LIMITS, I HAVE ALSO SIGNED THE CALIFORNIA PERSONAL AUTO SUPPLEMENT.
IN ADDITION, I HAVE BEEN OFFERED WAIVER OF COLLISION DEDUCTIBLE. IF THIS OPTION IS NOT INDICATED ON THIS APPLICATION, THEN I HAVE REJECTED THIS OPTION.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INSDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
APPLICANT'S SIGNATURE
DATE
PRODUCER'S SIGNATURE
-
-
$
-
-
-
-
-
X