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