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Plcyoth Plcyoth Document Transcript

  • THIS IS NOT PROOF OF INSURANCE THIS IS NOT PROOF OF INSURANCE APPLICANT QUESTIONNAIRE -- TO BE COMPLETED BY THE APPLICANT IN HIS/HER OWN HANDWRITING PLEASE MAKE SURE THE APPLICANT INITIALS EACH RESPONSE 1 Have all drivers, such as children away from home or in college, Yes No _______ Initial who may operate your vehicle(s) on a REGULAR basis or any INFREQUENT bases been listed on this application? If no, please explain. 2 Have all residents of your household been disclosed on this Yes No _______ Initial application? If no, please explain. 3 Do any operators have a medical, nervous, mental, or physical Yes No _______ Initial condition which could impair their ability to safely operate a vehicle? If yes, please explain. 4 Is every operator a United States citizen? Yes No _______ Initial 5 Do you understand that we do not cover losses if your vehicle is Yes No _______ Initial being operated by an undisclosed driver(s) resident in your household? If no, please explain. 6 Are all vehicles in the household listed on this application? If no, Yes No _______ Initial please explain. 7 Are any vehicles used for business purposes? (Examples: sales Yes No _______ Initial calls, driving to job sites, etc.) If yes, please explain. 8 Are any vehicles used for delivery purposes or for any other Yes No _______ Initial commercial purpose? (Examples: pizza or newspaper delivery.) If yes, please explain. 9 Do you understand that we do not cover losses if your vehicle is Yes No _______ Initial being used for commercial purposes? 10 Is there any unrepaired damage or glass breakage to any Yes No _______ Initial vehicle(s)? If yes, please explain. 11 Are any operators a member of the armed forces? If "yes", where Yes No _______ Initial stationed? 12 I agree to notify Infinity of any member of my household age 14 and Yes No _______ Initial older, licensed or not, and any change in driving status for any person currently listed or added on my policy, in the future. (By answering "Yes" I certify that I have read and understand my obligation pursuant to this provision and that this obligation continues for this policy, or any continuation, renewal or replacement of this policy by you.) THIS IS NOT PROOF OF INSURANCE VEHICLE 1 VEHICLE 2 VEHICLE 3 13 Annual mileage driven for: 14 Yes No Yes No Yes No 15 Type Apartment Condo Townhouse House Mobile Home Do you: Own Rent Other Residence: Explanations:
  • THIS IS NOT PROOF OF INSURANCE !" # $% &&% ' ( ) *( % ' &#+ ) , #( !- , . -! /# ( ! &#+ / !" # 00& ( ! ( " -1" #2 % ' ( " ( +' 2 ! ( ) 4 33333 5 6 33333 7 8 49 33333 8 8 49 9 33333 : 1 ) 4; 33333 < 8 33333 = . ( + #2-! ( + !" ! ( % ( # ) ># 0#2, -- % ( !% + 2 ># !" # ( -. 2#+ . !% , . -! " % &+ > & + 33333 + 2 >#2? & #( -# - @ $. 2!" #2 ) 2## !" ! $ , + % ' ( 0 , #( ! % 2 $. && 0 , #( ! " # * - 2#!. 2( #+ / !" # / ( * 33333 /# . -# % $ ( % ( 5-. $$ #( ! $. ( + - % >#2 ) # ' && /# ( . && ( + >% + $2% , ( #0! % ( A ! " #$ & %" %' ( !)$ ( % * +5 B ! C B 0 333333333 333333332 C " , "# - ( %' * +5 D D 8 D! D 8 333333333 333333332 C - 3333333333333333333333333333333333333333 + 33333333333333 ! 333333333333 . 8 E 5 E 5 E 1 5 5 F- James Moran + ! & ( 734134
  • THIS IS NOT PROOF OF INSURANCE Underwritten by: UNINSURED/UNDERINSURED MOTORIST COVERAGE SELECTION/REJECTION FORM GEORGIA Named Policy Insured: ID Number: In accordance with the provision of state law respecting Automobile Liability Insurance which permits the named insured in the policy to reject or accept Uninsured Motorist Coverage, the undersigned insured does understand that he or she has the right to purchase Uninsured Motorist Coverage with limits not to exceed the liability limits of this policy. The undersigned insured does hereby, for this policy and any renewal thereof, reject or accept as indicated below, such coverage provided for protection of persons insured under this policy who would legally be entitled to recover damages from the owner or operator of an uninsured motor vehicle because of bodily injury, sickness or disease, including death resulting therefrom, and for injury to or destruction of property. REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE I Reject Uninsured/Underinsured Motorists Coverage and understand that my policy will not provide Uninsured/Underinsured Motorists Bodily Injury and Uninsured/Underinsured Motorists Property Damage Coverage. I understand Uninsured/Underinsured Motorists coverage and have been advised of the premiums. I understand and agree that my selection applies not only to this policy, but also to all renewals or replacements thereof, unless I instruct the Company to the contrary in writing. I understand that by rejecting Uninsured/Underinsured Motorists Bodily Injury and Uninsured/Underinsured Motorists Property Damage Coverage my policy will not provide this coverage. Insured Signature ____________________________________Date______________________ Time _________________ AM PM SELECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE/OPTIONS Uninsured Motorist Bodily Injury: Uninsured Motorist Property Damage: $25,000 / $50,000 $250 Deductible $25,000 each accident $50,000 / $100,000 $250 Deductible $50,000 each accident $100,000 / $300,000 $250 Deductible $100,000 each accident $500 Deductible $25,000 each accident $500 Deductible $50,000 each accident $500 Deductible $100,000 each accident $1,000 Deductible $25,000 each accident $1,000 Deductible $50,000 each accident $1,000 Deductible $100,000 each accident I Accept Uninsured Motorist Coverage Added on to At-Fault Liability Limits Option at the limits selected above I Reject Uninsured Motorist Coverage Added on to At-Fault Liability Limits Option and Accept Uninsured Motorist Coverage Reduced by At-Fault Liability Limits Option at the limits selected above All coverage and options for Uninsured Motorist Coverage have been offered and fully explained to me, and I knowingly made the selection above as reflected by the “X” in the appropriate box. I understand Uninsured Motorist Coverage Added on to At-Fault Liability Limits and Uninsured Motorist Coverage Reduced by At-Fault Liability Limits and have been advised of their premiums. I understand that by rejecting Uninsured Motorist Coverage Added on to At-Fault Liability Limits my policy will not provide this coverage and I accept the Uninsured Motorist Coverage Reduced by At-Fault Liability Limits Option. I understand and agree that my selection applies not only to this policy, but also to all renewals or replacements thereof, unless I instruct the Company to the contrary in writing Insured Signature _______________________________________ Date ___________________ Time ________________ AM PM THIS IS NOT PROOF OF INSURANCE Form Number Page 1 of 1 View slide
  • THIS IS NOT PROOF OF INSURANCE Uninsured Motorist Informational Notice If you have chosen to accept Uninsured Motorists coverage from your automobile insurance company, and have any questions after reading this statement regarding Uninsured Motorists coverage or the amount of coverage you have selected, your agent or company representative will be able to assist you. You should have chosen the amount of Uninsured Motorists coverage you want based on this question: If I get hit by someone with little or no liablity insurance, how much protection do I need to cover the cost associated with car repair, medical bills, other expenses, and lost wages? If the person who hits your automobile has no liability coverage or liability coverage equal to or less than the Uninsured Motorists amount you chose, your total automobile insurance recovery (from all companies involved) may not exceed the amount of Uninsured Motorists coverage you chose. The purpose of this notice is informational. This notice does not change or replace the wording in your policy. X_________________________________ _____________ Signature of Applicant Date THIS IS NOT PROOF OF INSURANCE View slide
  • THIS IS NOT PROOF OF INSURANCE INFINITY VALUE ADDED PROGRAM AGREEMENT VOIDING AUTOMOBILE INSURANCE WHILE A CERTAIN PERSON IS OPERATING YOUR INSURED AUTO FORM #03937 N1102 In consideration of YOUR premium payment, it is agreed that, with respect to the insurance afforded under this policy, or any continuation, renewal or replacement of the policy BY you, or the reinstatement of this policy within 30 days of any lapse thereof, WE shall not be liable for loss, damage, or liability caused when YOUR INSURED CAR is being driven or operated by the person named below. NAME OF PERSON BEING EXCLUDED SOCIAL SECURITY NUMBER OF PERSON BEING EXCLUDED It is further agreed that in the event WE shall, because of any interest, become obligated to pay any sum or sums of money because of loss for which there would be no coverage because of this agreement, YOU will reimburse US for any and all sums, costs and expenses paid or incurred by US. CAUTION: DO NOT SIGN THIS AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND IT. APPLICANT'S SIGNATURE DATE TIME LESSOR LIABILITY ENDORSEMENT ACKNOWLEDGMENT FORM #03940 N1102 I understand that I have requested the 'Lessor Liability Endorsement' to be included as part of my contract of insurance. I have signed this form as an indication that I have read, understood and agree with the endorsement and the limitations it places on my coverage as outlined therein and below. I understand that the endorsement is only effective on a vehicle that has been leased by me for a period of at least six (6) months as documented by a standard form lease agreement with expressly stated insurance coverage requirements. I understand that the limits of coverage for damages I become legally obligated to pay, as defined by my policy, shall be those limits listed on my Declarations Page. I understand that this endorsement and the coverage provided therein will only apply to damages that my lessor becomes legally obligated to pay and that arise from and are related to a loss covered under my policy. I understand that the coverage provided by this endorsement is in addition to that listed on my Declarations Page and is only available to indemnify my lessor pursuant to the terms listed in the endorsement. I understand that the coverage provided by this endorsement shall in no event increase the limits of liability for any damages I become legally obligated to pay pursuant to the terms of my policy. I also understand that the lessor is not responsible for payment of my premium. Applicant's Signature Date Applicant's Signature Date THIS IS NOT PROOF OF INSURANCE
  • INFINITY VALUE ADDED PROGRAM AUTHORIZATION FOR INSURED'S ELECTRONIC FUND TRANSFERS Fax voided personal check along with this form to be set up for IEFT and retain the original for your records: 1-888-682-8231 - Attn: GENERAL ACCOUNTING INSURED'S NAME: POLICY NUMBER: EFF DATE: I, give Infinity the authorization to withdraw the appropriate Infinity money that has been deposited into my account I further authorize the financial institution named below to accept such automatic deposits to or withdrawals from my account by Infinity and to automatically credit or debit, as the case may be, such amounts. Name of Bank: Address: City, State, Zip: Phone: The routing and account numbers provided on the copy of the voided personal check will be used to set up the Insured's Electronic Funds Transfer (i.e. IEFT). I understand that I may cancel this authorization at any time. To cancel, I must give notice to the company, in writing. My cancellation will become effective when the company receives written notice of cancellation and has a reasonable period of time upon which to process the change. I further understand that all automatic deposits to or withdrawals from my account under this authorization will be subject to all rules, regulation, agreements, and disclosure statements of the company and the institution governing accounts and pre-authorized transfers to and from this account. Your bank will be notified that Infinity will have authorization to make withdrawals or transfers on this account. Name (Print) Address (Print) James Moran Agent's Name Insured's Signature Date ANY CHANGES TO EXISTING INSURED'S EFT Program: VALUEADDED CHECKING ACCOUNT OR BANK, MUST BE SUBMITTED IN WRITING IMMEDIATELY TO: GENERAL ACCOUNTING INFINITY INSURANCE COMPANY 2204 LAKESHORE DRIVE PO BOX 830189 BIRMINGHAM, AL 35283 THIS IS NOT PROOF OF INSURANCE 03895 N0902