Microsoft Word - 7982.NV.0616.docx

Policy and premium information for policy number <Policy Number>

Policy and premium information

..................................................................................................................................................................................................................................................

Insurance company: <Underwriting company name (UWC)>

<5 Digit agent code>

< Agent address >

< Agent city>, <Agent state><Agent Zip >

<5 Digit agent code >

< Agent phone number>

<* Second Named insured Full Name>

<*Name insured 2nd line address>

<*Foreign address>

Home: <Insured home phone number>

Membership number: <Membership Number>

Financial responsibility vendor: <Credit Vendor name>

Your policy will be effective when your required initial payment is received by your <agent/broker> or at a later date of your choice.

Total policy premium: <$XXXXXXX.XX>

Initial payment required: <$XXXXXXX.XX>

Policy Number: <xxxxxxxxxx>

<Policyholder/Policyholders>:

<*Additional Named Insure full name>

<Policyholder/Policyholders>:

Page <x> of <x>

Application for Insurance

Please review, sign where

indicated and return

Please review and sign where

indicated

Policy Number: <xxxxxxxxxx>

Page <x> of <x>

Initial payment received: <$XXXXXXX.XX>

Payment plan: <Payment method>

Policy period: <Policy effective date> - <Policy expire date>

Effective date and time: <Policy effective date> at <Policy effective time>

Total policy premium: <$XXXXXXX.XX>

Initial payment required: <$XXXXXXX.XX>

Unpaid balance: <$XXXXXXX.XX>

Minimum due: <$XXXXXXX.XX>

Initial payment received: <$XXXXXXX.XX>

Payment plan: <Payment method>

Your policy will be effective when your required initial payment is received by your <agent/broker> or at a later date of your choice.

Total policy premium: <$XXXXXXX.XX>

Initial payment required: <$XXXXXXX.XX>

Unpaid balance: <$XXXXXXX.XX>

Minimum due: <$XXXXXXX.XX>

Initial payment received: <$XXXXXXX.XX>

Payment plan: <Payment method>

Drivers and resident relatives

The applicant, spouse or domestic partner, and all resident relatives <Household Residents Minimum Age> years of age or

older, all regular drivers of the vehicles described in this application, and all children who live away from home who drive these

vehicles, even occasionally, are listed below. Your total policy premium can be affected by all persons of driving age. While

designating drivers as List Only or Excluded may increase policy premium, the violation and accident history of Excluded and List

Only drivers does not affect premium.

Name Date of birth Sex Marital status Relationship

Driver status: <Driver Status>

Education level: <Education Level description>

Occupation: <occupation description>

Named non-owner

Additional information

Education level: <Education Level description>

Occupation: <occupation description>

Policy Number: <xxxxxxxxxx>

Page <x> of <x>

Driver filing

Name

Filing type: <filing type 1> <filing type 2> <filing type 3> <filing type 4>

State: <filing state 1 > <filing state 2> <filing state 3> <filing state 4>

Case number:

Outline of coverage

Your insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown

for a vehicle may not be combined with the limits for the same coverage on another vehicle.

General policy coverage

Limits Deductible Premium

<Coverage description> <Limits> free

<Coverage description> <Limits> included

Total premium for general policy coverage <$x>

Total premium for general policy coverage --

VIN: < Vehicle VIN number>

Garaging ZIP Code: <Garaging Zip>

Primary use of the vehicle: <use>

Length of vehicle ownership when policy started or vehicle added: <Length of time vehicle is owned/leased>

Information regarding your vehicle history (prior damage, theft or title issues) has impacted how we determine your premium.

We were unable to validate or locate prior history for the VIN you provided, which has impacted how we determine your premium.

This vehicle is currently enrolled in the <UBI program name>

℠ Program.

Limits Deductible Premium

< Coverage description > <Limits> <Deductible> <$X>

< Coverage description > * <Deductible> <X>

< Coverage description > <Limits> <Deductible> <X>

< Coverage description > <Limits> <Deductible>

< Coverage description > <Limits> <Deductible> <X>

< Coverage description > <Limits> <Deductible> free

< Coverage description > <Limits> <Deductible> included

Total premium for<Vehicle year> < Vehicle make> <$x>

* In the event of a total loss of this vehicle, the maximum amount payable is the lesser of the actual cash value or the stated amount of <stated amount>.

* In the event of a loss, the maximum amount payable is the lesser of the actual cash value, subject to the deductible, or the limit of <stated amount>.

Subtotal policy premium <$xxx.xx>

Policy Number: <xxxxxxxxxx>

Page <x> of <x>

<+> Total <term length> month policy premium <*and fees> <1$xxx.xx>

<+> Total <term length> month policy premium, with paid in full discount <*and fees> <2$xxx.xx>

+ Includes the Deductible Savings Bank

feature

Other features and benefits

Deductible Savings Bank

Your savings will increase with every accident and violation free policy term

Premium discount

Premium discounts

Policy

Driver

Vehicle

Additional policy information

Policy

Driver

Vehicle

Driving history

Driving history (continued)

Please review the following information carefully because driving history is used to determine your premium. All accidents are

considered at-fault and over any applicable payment threshold unless we receive additional information from you or another

source that proves otherwise. We obtain driving and claims history from one or more of the following sources:

 Your application (APP) • Motor Vehicle Reports and/or court data (MVR) - provided by

a consumer reporting agency

 Progressive claims history (PROG) • Comprehensive Loss Underwriting Exchange (CLUE) - provided by

a consumer reporting agency

Driver and Description Date Source/Consumer reporting agency

Underwriting information

Policy Number: <xxxxxxxxxx>

Page <x> of <x>

Prior insurance: <Prior Insurance Description>

Prior insurance carrier: <POP insurance carrier name>

Policy number: <POP policy number>

Bodily injury limits: <Proof of prior BI limits>

Lienholder and additional interest information

Lienholder information

Additional interest information

Vehicle Lienholder Additional interest

<*Lienholder name> <*Additional Interest name>

<*LH City, state zip> <*AI City, state zip>

Vehicle Additional interest

Vehicle Lienholder

<*Lienholder /Additional Interest name>

<*City>, <*State> <*ZIP>

rr <HDR-RATE-REV-MM><HDR-RATE-REV-YY>, c <PMD-COMMISSION>, rp <PMD-RATE-PLAN>, bp <ARB-BILL-PLN-CD>This application has been electronically transmitted.

Offer of Uninsured/Underinsured Motorist coverage

If you purchase this coverage, Uninsured/Underinsured Motorist coverage would protect you, your resident relatives, and

occupants of a covered vehicle if any of you sustain bodily injury, including any resulting death, in an accident for which the

owner or operator of a motor vehicle who is legally liable does not have insurance (an uninsured motorist) or does not have

enough insurance (an underinsured motorist).

You may purchase Uninsured/Underinsured Motorist coverage up to the limits of the Bodily Injury Liability coverage that you

have selected. You may not purchase Uninsured/Underinsured Motorist coverage with limits that exceed the limits of the Bodily

Injury Liability coverage selected. Uninsured/Underinsured Motorist coverage

may not be added, combined, or stacked together

regardless of the number of vehicles listed on the policy.

Offer of Medical Payments coverage

If you purchase this coverage, Medical Payments coverage provides protection, without regard to legal liability, for reasonable

and necessary medical and funeral expenses incurred by an insured person who sustains bodily injury in an accident while

operating or occupying a covered vehicle or when struck as a pedestrian by a motor vehicle or trailer.

You may purchase Medical Payments coverage in an amount of $1,000 as well as higher optional limits. This coverage may not

be added, combined, or stacked together regardless of the number of vehicles listed on the policy.

Policy Number: <xxxxxxxxxx>

Page <x> of <x>

Application agreement

Verification of content

I declare that the statements contained herein are true to the best of my knowledge and belief and do agree to pay

any surcharges applicable under the Company rules which are necessitated by inaccurate statements. I declare that

no persons other than those listed in this application regularly operate the vehicle(s) described in this application. I

declare that none of the vehicles listed in this application will be used to carry persons or property for compensation

or a fee, or for retail or wholesale delivery, including, but not limited to, the pickup, transport, or delivery of

magazines, newspapers, mail, or food. I understand that this policy may be rescinded and declared void if this

application contains any false information or if any information that would alter the Company's exposure is omitted or

misrepresented.

Notice of information practices

I understand that to calculate an accurate price for my insurance, the Company may obtain information from third

parties, such as consumer reporting agencies that provide driving, claims and credit histories. The Company may use a

credit-based insurance score based on the information contained in the credit history. The Company or its affiliates may

obtain new or updated information to calculate my renewal premium or service my insurance. I may access information

about me and correct it if inaccurate. In some cases, the law permits the Company to disclose the information it collects

without authorization. However, the Company will not share personal information with nonaffiliated companies for

their marketing purposes without consent. Complete details are in the Company's Privacy Policy, which will be

provided with this insurance policy and upon request.

Acknowledgement and agreement

 If I make my initial payment by electronic funds transfer, check, draft, or other remittance, the coverage

afforded under this policy is conditioned on payment to the Company by the financial institution. If the

transfer, check, draft, or other remittance is not honored by the financial institution, the Company shall be

deemed not to have accepted the payment and this policy shall be void.

 If I make my initial payment by credit card, the coverage afforded under this policy is conditioned on

payment to the Company by the card issuer. I understand that if the Company is unable to collect my initial

payment from the card issuer, the Company shall be deemed not to have accepted the payment and this

policy shall be void. I also understand that if I authorize a credit card transaction for any payment other

than the initial payment, this policy will be subject to cancellation for nonpayment of premium if the

Company is unable to collect payment from the card issuer. The Company is deemed "unable to collect" in

the following instances: (1) when I reach my credit limit on my credit card and the card issuer refuses the

charge; (2) when the card issuer cancels or revokes my credit card; or (3) when the card issuer does not pay

the Company, for any reason whatsoever, upon the Company's request.

 This insurance and personalized service is available at this price exclusively through a <Co Brand Name>

independent agent. <Co Brand Name> affiliated companies selling insurance directly have different prices

and products. The <UBI Program Name>

Program is not available from all <agents/brokers>.

 The Company may obtain information, including vehicle history information, from third parties. I understand that this

information may affect my policy premium or could result in a policy declination, cancellation, or nonrenewal.

Other charges

I understand that if I cancel this policy, any refund due will be computed on a ninety percent (90%) of a daily pro-rata basis.

This is a daily, accelerated method of calculating short-rate earned premium on cancellations. When I renew this policy, I

understand that the Company will refund premium on a daily pro-rata basis.

I agree to pay the installment fees shown on my billing statement that become due during the policy term and each

renewal policy term in accordance with the payment plan I have selected. I understand that the amount of these fees

may change upon policy renewal or if I change my payment plan. Any change in the amount of installment fees will be

reflected on my payment schedule.

I understand that a returned payment fee of <NSF fee> will be assessed to the balance due on my policy if any

Policy Number: <xxxxxxxxxx>

Page <x> of <x>

check offered in payment is not honored by my bank or other financial institution. Imposition of such charge shall not deem the

Company to have accepted the check unconditionally.

I agree to pay a late fee of <late fee> when the payment for the minimum amount due is not received or postmarked by the

premium due date. The amount of this fee may change upon policy renewal.

Applicant signature

I represent that I, <PNI full name>, am the person identified as the named insured and the first driver in the Drivers and

resident relatives section of this application. I acknowledge and agree to the statements contained within this application.

I also acknowledge and agree that by typing my name in the designated boxes on the screen below this form and clicking

"Continue", I am electronically signing this application, which will have the same legal effect as the execution of this document

by a written signature and shall be valid evidence of my intent and agreement to be bound by its terms.

I understand that my name already appears in the signature line below because I chose to electronically sign this application.

Signature of named insured Date

X<PNI full name> <PNI esign date>

Form 7982 NV (06/16)

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