ASSURANCEAMERICA INSURANCE COMPANY - …rater.accuauto.net/pdf/GA/amaappsp.pdf · PO Box 723128,...

_ ASSURANCEAMERICA INSURANCE COMPANY_______

NEW BUSINESS PACKAGE / NUEVO PAQUETE COMERCIAL COVER PAGE /PÁGINA DE LA PORTADA

To: AssuranceAmerica Underwriting Department/Para:Departamento de evaluación de riesgos de AssuranceAmerica Date/ Fecha: From/De: Pages Attached/Páginas adjuntas: Agency Code:/ Código de la agencia: Name:/ Nombre: Policy #:/ Nº de póliza: Thank you for choosing AssuranceAmerica for your automobile insurance needs! Gracias por elegir a AssuranceAmerica para sus necesidades en seguros automotrices. The following items must be faxed to AssuranceAmerica the same day the application is transmitted: Deben enviarse por fax los siguientes documentos a AssuranceAmerica en la misma fecha en que se transmita la solicitud:

Proof of Prior Insurance – Required when the insured qualifies for a Prior Insurance Discount. Prueba de seguro previo: Se requiere cuando el asegurado califica para un descuento por seguro previo.

Proof of Homeownership – Required when the insured qualifies for a Homeowner’s Discount. Prueba de título de propiedad: Se requiere cuando el asegurado califica para un descuento por ser propietario de una vivienda.

Proof of Mobile Homeownership – Required when the insured qualifies for a Mobile Homeowner’s Discount. Prueba de propiedad de casa rodante: Se requiere cuando el asegurado califica para un descuento por ser propietario de una casa rodante.

Proof of Defensive Driver Training Course. Prueba de asistencia al curso de entrenamiento de conducción segura.

Proof of Good Student Discount. Prueba de descuento por buen estudiante. Please do not send other documents unless requested by the company. No envíe otros documentos a menos que así lo solicite la compañía. The application and copies of other supporting documents must be completed and retained in your office. La solicitud y las copias de otros documentos secundarios se deben completar y conservar en su oficina. ***REMEMBER to take photographs of all vehicles with uninsured motorist

coverage or physical damage coverage*** ***RECUERDE tomar fotos de todos los vehículos con cobertura de conductor

no asegurado o de lesiones físicas***

ASSURANCEAMERICA INSURANCE COMPANY “Doing the expected… And then some!”

“Hacemos lo que tenemos que hacer y más” Telephone: (770) 952-0200

Fax: (770) 952-0258

Producer Code:/ Código del productor: Policy Id:/ Identificación de la póliza:

Additional Application Information Applicant: Company: ASSURANCEAMERICA INSURANCE Policy #:

POLICY NUMBER NÚMERO DE PÓLIZA AssuranceAmerica

Managing General Agency PO Box 723128, Atlanta GA 31139-0128

BOX 723128, ATLANTA, GEORGIA 31139-0128

AGENT CODE CÓDIGO DEL AGENTE

GA AGENCY NAME TELEPHONE NOMBRE DE LA AGENCIA TELÉFONO

GEORGIA Personal Car Application/ Solicitud para automóvil de uso personal

SR22A FILING □ Yes □ No (Attach current MVR for all Drivers) CERTIFICACIÓN SR22A □ Sí □ No (adjuntar el registro vehicular de todos los conductores)

Term / / To / / Time AM/PM Período / / a / / Hora AM/PM

PAYMENT OPTION/OPCIÓN DE PAGO □ Direct Bill/ Facturación directa ____ □ Paid in Full/ Pago completo ____ Down Payment/ Pago Inicial: $ (checks payable to AssuranceAmerica)/(cheques a nombre de AssuranceAmerica)

Applicant’s Name (Must be registered owner) SS # Nombre del solicitante (debe ser la persona que figure como propietaria) Nº SS ___________________________________________________________ Mail Address Dirección postal ___________________________________________________________ ___________________________________________________________ HOME PHONE: ( ) TELÉFONO PARTICULAR: ( )

Garage Location, if different from mail address/ Ubicación del garaje, si es diferente a la dirección postal:

Prior Insurance Carrier (Attach Proof) Policy Number Compañía de seguros anterior (adjuntar prueba) Núm. de póliza Termination Date Termination Reason Fecha de finalización Razón de la finalización

Employer Name/ Nombre del empleador : Phone #/ Nº de tel: Address/Dirección:

COVERAGE (Indicate coverage requested by placing check mark X in box. Be sure to include limits and deductible selections where necessary) COBERTURA (Indicar la cobertura que se solicita marcando con una X la casilla que corresponda. Asegúrese de incluir las opciones de deducibles y límites donde sea necesario)

Car Auto

Bodily Injury Property Damage / Lesiones físicas Daños a la propiedad

Medical Payments/ Pagos médicos

UM Added-on / UM Agregado

UM Rejected/ UM Rechasado

AD&D $10/ $1,000/ Muerte accidental y desmem-bramiento $10/ $1,000

Comp & Collision/ Daños integrales y por colisión

Spec Equip/ Equipo especí-fico

LOU/ Inutiliza-ción

Sub Total/ Sub Total

Applicable Discounts/ Descuentos aplicables

$ 25,000 / $ 50,000 BI/LF

$25,000 PD/DP

____ FULL/ COMPLETA ____ LIMITED/ LIMITADA $_________

$ _______ Deductible/ Deducible

$ _______

$ _______ Deductible/ Deducible

Attach list And receipts/ Adjuntar lista y recibos

$ 20 a day $400 per incident/ $ 20 por vehiculo $400 por incidente

1 $ $ $ $ $ $ $ $ 2 $ $ $ $ $ $ $ $ 3 $ $ $ $ $ $ $ $ Policy Fee $ Underwriting Fee $ SR22A Fee $ Tarifa de la póliza $ Tarifa de aseguramiento $ Tarifa de SR22A $

Total Premium/ Fees Total de la prima/ tarifas

$

□ Proof of prior (1-30 days lapse)/ Seguros previo (1-30 dias de lapso)

□ Proof of Prior (0 days lapse))/ Seguro previo (0 dias de lapso)

□ Multi-Car / Varios autos □ Homeowners / Propietarios de vivienda □ Safe Driver / Conductor seguro □ Good Student / Buen estudiante □ Paid in Full / Pago complete □ EFT

VEHICLE INFORMATION (In order of highest rated vehicles first) / INFORMACIÓN DEL VEHÍCULO (Siguiendo el orden del vehículo más caro primero) Car Auto

Year Año

Make & Model Marca y modelo

Body type Tipo de carrocería

Vehicle Identification Number Número de identificación del vehículo

Symbol Símbolo

Surcharge Recargo

4WD 4WD

1

2

3 LEINHOLDER INFORMATION / INFORMACIÓN DEL ACREEDOR Car Auto

NAME NOMBRE

ADDRESS DIRECCIÓN

CITY/STATE CIUDAD/ESTADO

ZIP CP

1

2

3 DRIVER INFORMATION (Must list all persons age 14 and older, living in household OR having any regular vehicle use.) INFORMACIÓN DEL CONDUCTOR (Incluir en la lista a todas las personas mayores de 14 años que vivan en el mismo hogar O que usen el vehículo regularmente.) Driver/ Conductor

Name/ Nombre

Sex/ Sexo

Marital Status/ Estado civil

Relation to Insured/ Relación con el asegurado

Date of Birth Mm/dd/yy/ Fecha de nacimiento

Driver’s License Number/ Número de licencia del conductor

State/ Estado

# years licensed / Nº de años de licencia

Occupation/ Ocupación

1 Applicant/ Solicitante

Same/ Igual

2 3 4

AAG01 012011

AAG01 012011

DRIVING RECORD (List ALL accidents and violation occurrences during the past 36 months) HISTORIAL DE INFRACCIONES Y ACCIDENTES DE TRÁNSITO (Incluya TODOS los accidentes e incumplimientos ocurridos dentro de los pasados 36 meses) Driver Conductor

mm/dd/yy mm/dd/aa

Detail of Accident or Infraction SR22A? Case # Detalle del accidente o la infracción ¿SR22A? Nº de caso

Proof of No Fault? Proof must be attached ¿Prueba de no culpabilidad? Se debe adjuntar la prueba

Points Puntos

APPLICANT’S QUESTIONNAIRE CUESTIONARIO DEL SOLICITANTE 1. Are all listed vehicles registered/titled in your name/resident spouse? Ο Yes/ Ο No/ If no, disqualified for coverage 1. ¿Todos los vehículos de la lista están registrados/a nombre suyo/de su cónyuge residente? Sí No Si contestó que no, no califica para la cobertura

2. Has any driver been licensed in Georgia less than 3 years? Ο Yes/ Ο No/ 2. ¿Alguno de los conductores cuenta con una licencia de menos de tres años en Georgia? Sí No

If yes, most recently licensed in what state? Driver #1_____ #2_____ #3_____ #4_____ Si respondió que sí, ¿de qué estado es la licencia más reciente? Conductor Nº 1_____ Nº 2_____ Nº 3_____ Nº 4_____

3. Are there other vehicles in the household not listed on the application? Ο Yes/ Ο No/ If Yes, list owner’s name/insurer in Remarks Section 3. ¿Hay otros vehículos en su domicilio que no figuren en la solicitud? Sí No Si respondió sí, incluya el nombre del propietario/asegurador en la sección para comentarios

4. Does any driver or operator have a Suspended or Revoked license? Ο Yes/ Ο No/ If Yes, please explain in Remarks Section 4. ¿Alguno de los operadores o conductores tiene su licencia Sí No Si respondió que sí, explique en la sección para comentarios suspendida o revocada?

5. Are you or any other driver self-employed? Ο Yes/ Ο No/ If Yes, please explain in Remarks Section 5. ¿Usted u otro de los conductores trabajan por cuenta propia? Sí No Si respondió que sí, explique en la sección para comentarios

6. Is any insured vehicle used in any way in your business or occupation? Ο Yes/ Ο No/ If Yes, please explain in Remarks Section 6. ¿Algunos de los vehículos asegurados se utiliza de alguna manera en Sí No Si respondió que sí, explique en la sección para comentarios su negocio u ocupación?

• Do you or any other driver ever carry passengers to job sites? Ο Yes Ο No If Yes, please explain in Remarks Section • ¿En ocasiones usted u otro conductor llevan a otros pasajeros a Sí No Si respondió que sí, explique en la sección para comentarios lugares de trabajo?

• Do you or any other driver ever carry occupational equipment or materials? Ο Yes/ Ο No/ If Yes, please explain in Remarks Section

• ¿En ocasiones usted u otro conductor llevan equipos o materiales del trabajo? Sí No Si respondió que sí, explique en la sección para comentarios

7. Is any vehicle driven across state lines for business or school? Ο Yes/ Ο No/ If Yes, please explain in Remarks Section 7. ¿Alguno de los vehículos debe cruzar las fronteras estatales para dirigirse Sí No Si respondió que sí, explique en la sección para comentarios a la escuela o el trabajo?

8. Is auto driven over 50 miles one way to work or school? Ο Yes/ Ο No/ If Yes, please explain in Remarks Section 8. ¿El auto debe recorrer más de 50 millas para dirigirse al trabajo o a la escuela? Sí No Si respondió que sí, explique en la sección para comentarios

9. Do you, or any driver, have any physical or mental impairment? Ο Yes/ No/ If Yes, please explain in Remarks Section 9. ¿Usted u otro de los conductores sufre de alguna discapacidad física o mental? Sí No Si respondió que sí, explique en la sección para comentarios

10. Is there any unrepaired damage of any kind to any car or truck listed? Ο Yes/ Ο No/ If yes, photos and Agent’s inspection must be attached 10. ¿Alguno de los autos o camionetas en la lista tiene daños que no se Sí No Si respondió que sí, debe adjuntar fotos y la inspección del han reparado? agente

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFICIARY BENEFICIARIO POR MUERTE ACCIDENTAL Y DESMEMBRAMIENTO I select this coverage, as shown on the front of this application, and designate the following beneficiary: Elijo esta cobertura, según se indica en el frente de esta solicitud, y designo al siguiente beneficiario: Beneficiary’s name/ Nombre del beneficiario ___________________________________________________________________________ Address/ Dirección________________________________________________________________________________________________ REMARKS / EXPLANATION COMENTARIOS/ EXPLICACIÓN ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AAG01 012011

MEDICAL PAYMENTS COVERAGE COBERTURA DE GASTOS MÉDICOS

I understand no medical coverage is automatically afforded under this policy and I elect the following Medical Payments coverage and reject all other options.

Comprendo que esta póliza no concede ninguna cobertura médica de manera automática. Elijo la siguiente cobertura de Gastos médicos y rechazo todas las otras opciones.

ο FULL coverage/ Cobertura COMPLETA ο $1,000 ο $2,000 ο $ _________________ (Other limits submit unbound) / (Presentar otras limitaciones por separado)

ο LIMITED coverage/ Cobertura LIMITADA ο $1,000 ο $2,000 ο $ _________________ (Other limits submit unbound) / (Presentar otras limitaciones por separado)

ο REJECTION of MEDICAL PAYMENTS COVERAGE/ RECHAZO de la COBERTURA DE GASTOS MÉDICOS

The Medical Payments coverage options have been fully explained to me and in consideration of a reduced premium, I fully understand that, with respect to the insurance afforded under Medical Payments, the definition of “reasonable medical expenses shall not include treatment, services, procedures or products that are chiropractic or delivered under the direction or supervision of a chiropractor. This endorsement also excludes treatment, services, procedures or products that are incurred for the use of thermography or acupuncture, or the purchase or rental of equipment not primarily designed to serve a medical purpose.

Se me han explicado completamente las opciones de Gastos médicos y en consideración de la reducción de la prima y comprendo enteramente que, con respecto al seguro de Gastos médicos, la definición de "gastos médicos razonables" no incluye tratamientos, servicios, procedimientos o productos de quiropráctica o que se realicen bajo la supervisión o dirección de un profesional de la quiropráctica. Esta aprobación también excluye tratamientos, servicios, procedimientos o productos que deriven del uso de termografía o acupuntura, o la compra o renta de equipos que no hayan sido diseñados específicamente para usos médicos.

This additional option for Medical Payments coverage has been fully explained to me and I knowingly and willingly made the selection to accept this limitation to the Medical Payments coverage, as indicated by my signature below. Se me ha explicado enteramente la opción adicional de cobertura de Gastos médicos y he optado, voluntariamente y a sabiendas, por aceptar esta limitación a la cobertura de Pagos médicos, como queda indicado por mi firma debajo.

DO NOT SIGN TO ACCEPT LIMITED COVERAGE UNTIL YOU HAVE READ AND UNDERSTAND THE CONDITIONS NOTED ABOVE.

NO FIRME LA ACEPTACIÓN DE LIMITACIÓN DE COBERTURA HASTA NO HABER LEÍDO Y COMPRENDIDO LAS CONDICIONES QUE FIGURAN ARRIBA.

X Applicant’s Signature/ Firma del solicitante ________________________________________________________________________________

UNINSURED MOTORIST COVERAGE COBERTURA CONTRA CONDUCTORES SIN SEGURO

I elect the following Uninsured Motorists coverage subject to any applicable deductible for Property Damage by Georgia law. I understand that I have the right to purchase Uninsured Motorist coverage with limits not to exceed the liability limits of this policy. In accordance with the provision of the state law respecting Automobile Liability insurance which permits the insured named in the policy to reject or accept as indicated below, the Uninsured Motorists coverage, the undersigned insured does hereby, for the above policy and any renewal thereof, reject or accept as indicated below, such coverage provided the 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, or property damage. Hago mi elección en cuanto a la siguiente cobertura contra Conductores sin seguro sujeta a cualquier deducible que corresponda para daños a la propiedad según lo establecido por la ley de Georgia. Comprendo que tengo el derecho de comprar la cobertura contra Conductores sin seguro con limitaciones que no excedan las limitaciones de responsabilidad de esta póliza. De acuerdo con las disposiciones de la ley estatal respecto al seguro de Responsabilidad automotriz que permite al titular de la póliza rechazar o aceptar, según se indica debajo, la cobertura contra conductores sin seguro, el que suscribe, en relación con la póliza que figura arriba y las renovaciones de la misma, rechaza o acepta, por la presente y según se indica debajo, dicha cobertura siempre que se provea la protección a las personas aseguradas en esta póliza, que tendrán derecho legal de obtener compensación por los daños que provengan del propietario u operador de un automotor sin seguro por lesión física o enfermedad, incluyendo la muerte que resulte como consecuencia, o daños a la propiedad.

o I ACCEPT ADDED-ON UNINSURED MOTORIST COVERAGE / ACEPTO COBERTURA AGREDADA DE CONDUCTOR SIN SEGURO

$25,000/$50,000/$25,000 LIMITS/ COMO LÍMITE $250_____DEDUCTIBLE/ DEDUCIBLE $500_____ DEDUCTIBLE/ DEDUCIBLE $1000______ DEDUCTIBLE/ DEDUCIBLE

o I REJECT ADDED-ON UNINSURED MOTORIST COVERAGE AND I ACCEPT REDUCED UNINSURED MOTOTIRST COVERAGE / RECHAZO CONDUCTOR SIN SEGURO AGREGADO Y ELIJO ACEPTAR COBERTURA DECONDUCTOR SIN SEGURO REBAJADO

$25,000/$50,000/$25,000 LIMITS/COMO LIMITE $250 ____ DEDUCTIBLE/DEDUCIBLE $500 ___ DEDUCTIBLE/DEDUCIBLE $1000___ DEDUCTIBLE/DEDUCIBLE o I REJECT UNINSURED MOTORIST COVERAGE IN ITS ENTIRETY/ RECHAZO EN SU TOTALIDAD LA COBERTURA DE CONDUCTOR NO

ASEGURADO THE ADDITIONAL OPTIONS FOR UNINSURED MOTORIST COVERAGE HAVE BEE N FULLY EXPLAINED TO ME. I UNDERSTAND MY OPTIONS FOR THIS COVERAGE AND I MADE MY SELECTION AS REFLECTED BY MY “X” IN THE APPROPRIATE BOX, ABOVE. SE ME HAN EXPLICADO TODAS LAS OPCIONES ADICIONALES PARA LA COBERTURA CONTRA CONDUCTORES SIN SEGURO. COMPRENDO MIS OPCIONES PARA ESTA COBERTURA E HICE MI ELECCIÓN INDICADA POR LA MARCA “X” EN LA CASILLA CORRESPONDIENTE. X Applicant’s Signature/ Firma del solicitante ______________________________________________________________________ PUNITIVE DAMAGES EXCLUSION EXCLUSIÓN DE DAÑOS PUNITIVOS

I ACCEPT the Punitive Damages Exclusion at the reduced premium/ ACEPTO la exclusión de daños punitivos por una reducción en la prima. I do not want to exclude Punitive Damages/ No quiero excluir los daños punitivos.

By accepting the Punitive Damages Exclusion, I understand that the Liability insurance provided by the policy will not apply to payment of any punitive or exemplary damages arising from any and all claims under the policy.

Al aceptar la exclusión de daños punitivos, comprendo que el seguro de responsabilidad civil que provee la póliza no cubrirá pagos por daños ejemplares o punitivos que surjan de cualquier reclamo bajo esta póliza.

X Applicant's Signature/ Firma del solicitante _______________________________________________________________ _______________________________________________________________________________________________________________

APPLICANT’S STATEMENT DECLARACIÓN DEL SOLICITANTE

I hereby apply to the company for a policy of insurance. I understand that the information provided by me, as attested by my signature below, is material to the company’s agreement to issue a policy of automobile insurance, and that if information given herein is false, misleading or materially affects the conditions under which this policy shall become null and void. HAVING HAD ALL THESE OPTIONAL COVERAGES AND OPTIONAL LIMITS OFFERED AND EXPLAINED TO ME, I HEREBY SIGN FOR THE ACCEPTANCES OR REJECTIONS OF COVERAGE FOR THIS POLICY AND RENEWAL, REPLACEMENT, REINSTATEMENT, TRANSFER, OR SUBSTITUTE THEREOF AND FOR ANY ADDITIONAL OR SUBSTITUTION OF ANY MOTOR VEHICLE COVERED BY SUCH POLICY.

Por medio del presente documento, solicito a la compañía una póliza de seguro. Comprendo que la información que he suministrado, tal como lo avala mi firma debajo, es esencial para el acuerdo de la compañía en la emisión de una póliza de seguro automotriz, y que si la información que figura aquí es falsa, engañosa o afecta materialmente las condiciones establecidas en esta póliza, se anulará e invalidará la misma. SE ME HAN OFRECIDO TODAS ESTAS COBERTURAS Y LIMITACIONES OPCIONALES JUNTO CON LA EXPLICACIÓN DE LAS MISMAS Y POR EL PRESENTE DOCUMENTO CERTIFICO CON MI FIRMA LA ACEPTACIÓN O EL RECHAZO DE LA COBERTURA DE ESTA PÓLIZA Y SU RENOVACIÓN, REEMPLAZO, RESTITUCIÓN, TRANSFERENCIA O SUSTITUCIÓN ASÍ COMO CUALQUIER SUSTITUCIÓN O ADICIÓN DE CUALQUIER AUTOMOTOR CUBIERTO POR DICHA PÓLIZA.

I understand that information regarding my driving record and the driving record of all individuals listed on this application will be secured by the insurance company. The company may also secure driving records on any individuals whose residence address is the same as yours, whether or not listed on this application and may use the information to determine eligibility for the insurance policy. The company may also secure accident or claim information from other insurance companies or insurance support organizations. This information may also be used to determine premium and/or eligibility for the insurance policy. Comprendo que la compañía aseguradora procurará información relacionada con mi historial de infracciones y accidentes de tránsito y el historial de infracciones y accidentes de tránsito de todas las personas anotadas en esta solicitud. La empresa también podrá procurar el historial de infracciones y accidentes de cualquier individuo domiciliado en la misma dirección que la mía, esté o no inscrito en esta solicitud, y que podrá usar dicha información para determinar la elegibilidad de la póliza de seguro. La compañía también podrá obtener información sobre accidentes y reclamos a otras compañías de seguro u organizaciones de apoyo en relación a los seguros. Esta información también se podrá usar para determinar la prima y elegibilidad a la póliza de seguro. I agree that the insurance company has my permission to charge the correct rates and if the correct premium is not paid, I understand that the policy will be cancelled for non-payment of premium based on the correct premium developed. I further agree that if my down payment or full payment check is returned by the bank because of non-sufficient funds, coverage will be null and void from inception.

Acepto y otorgo mi permiso a la compañía de seguros para cobrar las tarifas que correspondan y en caso que no se pague la prima que corresponda entiendo que se cancelará la póliza por incumplimiento en el pago basado en la prima correcta. Acepto también que si el banco rechaza el cheque por el pago total o parcial, por falta de fondos suficientes, la cobertura será nula y no válida desde el comienzo de la misma.

IMPORTANT: All coverages must indicate accepted or rejected and all appropriate boxes checked before being signed by applicant. If Uninsured Motorists Coverage rejection form is not fully completed and signed, the policy will be issued with Uninsured Motorist coverages included and the appropriate premium charged. Any other box for an optional coverage not checked indicates my rejection of the option.

IMPORTANTE: Se debe indicar la aceptación o rechazo para todas las coberturas y se deben marcar todas las casillas correspondientes antes que el solicitante firme el documento. En caso en que no se complete en su totalidad el formulario de rechazo de Cobertura contra conductores sin seguro, la póliza incluirá las coberturas contra conductores sin seguro incluidas y se computará la prima correspondiente. Toda otra casilla de una cobertura opcional que no esté marcada indica que se rechaza dicha opción.

TRANSLATION: In order to facilitate the understanding of this application, a Spanish translation is provided for applicants presenting a limited knowledge or command of the English language. However, the English version of this application will prevail as the official language between the company and the applicant.

TRADUCCION: Para facilitar la comprensión de los términos de este aplicación, se proporciona una traducción en Español de los mismos para los solicitantes que tengan un conocimiento limitado o escaso dominio del Idioma Ingles. Sin embargo, la versión en Ingles de esta aplicación prevalecerá como la aplicación oficial entre la compañía y el solicitante.

I HEREBY ALLOW THE COMPANY TO RETAIN MY APPLICATION INCLUDING MY SIGNATURES UNDER FACSIMILE COPY AND/OR COMPUTER-SCANNED REPRODUCTION IN PLACE OF THE ORIGINAL FORM AND I WILL NOT DISPUTE THE USE OF SUCH REPLICATION AS ORIGINALS.

POR EL PRESENTE DOCUMENTO OTORGO PERMISO A LA COMPAÑÍA PARA CONSERVAR MI SOLICITUD, INCLUIDAS MIS FIRMAS, EN UNA COPIA FACSIMILAR Y/O REPRODUCCIÓN POR ESCÁNER EN UNA COMPUTADORA, EN LUGAR DEL DOCUMENTO ORIGINAL Y EL USO DE LA RÉPLICA COMO

DOCUMENTO ORIGINAL NO SERÁ MOTIVO DE CONFLICTO.

Date and Time/ Fecha y hora οAM οPM X Applicant’s signature/ Firma del solicitante_____________________________ ο AGENT’S STATEMENT/DECLARACIÓN DEL AGENTE As a duly licensed agent of the state of Georgia, I hereby certify that to the best of my knowledge, all information contained herein is correct, the statements herein are those of the applicant who has signed this application in my presence, and that the applicant and the undersigned are retaining a duplicate signed copy hereof. I am legally qualified to submit this application on behalf of the applicant. I also certify that each of the coverages available on this policy, including Uninsured Motorist Coverage, Medical Payments Coverage, and their options, have been fully explained to the applicant.

En mi carácter de agente debidamente acreditado del estado de Georgia, certifico por el presente que, según mi leal saber y entender, toda la información aquí incluida es correcta, que las declaraciones aquí incluidas corresponden al solicitante que ha firmado esta solicitud frente a mi y que el solicitante y el abajo firmante conservan una copia firmada del presente documento. La ley me califica para presentar esta solicitud en nombre del solicitante. También certifico que cada una de las coberturas disponibles en esta póliza, incluyendo la Cobertura contra conductores sin seguro, Cobertura de gastos médicos, y otras opciones, se le han explicado en su totalidad al solicitante.

I CERTIFY THAT I HAVE PERSONALLY INSPECTED ALL VEHICLES LISTED ON THIS APPLICATION. CERTIFICO QUE HE INSPECCIONADO PERSONALMENTE TODOS LOS VEHÍCULOS QUE FIGURAN EN ESTA SOLICITUD.

ο Agent’s retained disclosure form: Date and time _____/____/_____ _______ οAM / οPM / El agente conserva un formulario para la divulgación: Fecha y hora

Agent’s Signature /Firma del agente ____________________________________ AAG01 012011

Additional Application Information Applicant: Company: ASSURANCEAMERICA INSURANCE Policy #:

AssuranceAmerica Insurance Company - ATLANTA, GA Policy Number

POLICY PERIOD

EFFECTIVE: ____ ____ ______ EXPIRATION: ____ ____ ______ 12:01AM

COVERAGE PROVIDED IN THE PERSONAL CAR POLICY DECLARATIONS (New Business)

NAMED INSURED(S) PRODUCER

Veh #

State Class Terr Total Pts

Veh S/C

AF S/C

Business Use

Age Model YR

Make Model/ Body Type

Vehicle Identification Number

LOSS PAYEE/ADDITIONAL INTEREST Veh # Type Lienholder Loan Number

DRIVERS Drv # Name DOB Age Marital Status Sex Driver’s Lic # Points Lic State Surcharge Status

CURRENT COVERAGES Coverages Limits Of Liability Veh 1 Veh 2 Veh 3 Veh 4

Vehicle Totals

FORMS AND ENDORSEMENTS MADE PART OF THIS POLICY:

GA-1 (6/99), GA-2 (6/99), E-1 (6/99), E-2 (6/99), E-10 (6/99), E-12 (5/01)

DISCOUNTS -

Total Premiums

Policy Fee

Underwriting Fee

Total Fees

Total Policy Premium

COUNTERSIGNED:

GA-2(6/99) PLEASE DETACH YOUR IDENTIFICATION CARD BELOW AND KEEP IN YOUR CAR AS PROOF OF INSURANCE Printed:

Sym

SR22A Fee

GEORGIA INSURANCE POLICY

INFORMATION CARD

AssuranceAmerica Insurance Company

POLICY# EFFECTIVE EXPIRES

YEAR: MAKE: MODEL: VIN:

INSURED: AGENT:

The current status of actual motor vehicle liability insurance coverage is maintained by the Georgia Department of Motor Vehicle Safety and is accessible to law enforcement agencies upon a check of the vehicle registration.

KEEP THIS CARD IN YOUR MOTOR VEHICLE WHILE IN OPERATION.

IN CASE OF AN ACCIDENT: OBTAIN THE FOLLOWING INFORMATION AND CALL (888) 223-8409 TO REPORT YOUR CLAIM:

16. NAME AND ADDRESS OF ALL DRIVERS, INJURED PARTIES, WITNESSES AND LICENSE NUMBER OF EACH CAR.

17. NAME OF INSURANCE COMPANY AND POLICY NUMBER FOR EACH CAR INVOLVED

18. REPORT ACCIDENT TO POLICE AND DO NOT ACCEPT RESPONSIBILITY OR COMMENT ABOUT THE ACCIDENT TO ANYONE EXCEPT YOUR COMPANY REPRESENTATIVE OR TO POLICE IF REQUIRED.

REPORT ALL CLAIMS TO: (888) 223-8409

GA-2(6/99) AssuranceAmerica Claim Services

GEORGIA INSURANCE POLICY INFORMATION CARD




INSURED: AGENT:






INSURED: AGENT:




















INSURED: AGENT:









Policy Number:/ Número de póliza:_______________

APPLICANT'S STATEMENT DECLARACIÓN DEL SOLICITANTE

I have made application for insurance with AssuranceAmerica Insurance Company on the following vehicles: Solicité a AssuranceAmerica Insurance Company la cobertura de seguro para los siguientes vehículos:

1. ________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________

Signed/ Firma ________________________________________

I certify that I am the sole owner and hold legal title to the vehicles listed above and that all vehicles are garaged at the same location given on my policy. Certifico que soy el único propietario de los vehículos que se enumeran arriba, de los que poseo la titularidad legal, y que los mismos se encuentran estacionados en la dirección especificada en mi póliza.

Signed/ Firma ________________________________________

I certify that the only drivers of these vehicles are the drivers listed below. Certifico que los únicos conductores de estos vehículos son los que figuran debajo.

1. ________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________

Signed/ Firma ________________________________________

I certify that there are no other persons who have regular use of these vehicles. Certifico que ninguna otra persona usa estos vehículos regularmente.

I also understand that my policy may be cancelled or voided it I have failed to disclose all regular operators of the above vehicles. Comprendo también que se podrá cancelar o anular mi póliza si no informo sobre todas las personas que operen regularmente los vehículos nombrados arriba.

Signed / Firma ________________________________________ Date / Fecha ________________________________________

THE COVERAGE PROVIDED BY THIS POLICY SHALL NOT APPLY TO ANY CLAIMS WHEN THOSE CLAIMS RESULT FROM THE VEHICLE BEING USED,

DRIVEN, OPERATED OR MANIPULATED BY THE EXCLUDED DRIVER (S). LA COBERTURA QUE PROVEE ESTA PÓLIZA NO SE APLICARÁ A NINGÚN

RECLAMO QUE CORRESPONDA AL USO DEL VEHÍCULO BAJO LA OPERACIÓN, CONDUCCIÓN O MANIPULACIÓN DE UNO O MÁS

CONDUCTORES EXCLUIDOS.

This agreement applies to ALL coverages shown on the Declarations Page. Este acuerdo se aplica a TODAS las coberturas en la Página de declaraciones.

NAMED DRIVER EXCLUSION EXCLUSIÓN DE CONDUCTORES

In consideration of the premium charged and/or for the company accepting this risk, specific named drivers are excluded from coverage. En consideración del cargo de la prima y/o de la compañía que acepta este riesgo, se excluye en específico a los conductores que aquí se nombran. This agreement will apply to all future renewals, reinstatements and changes in this policy unless the company is notified in writing otherwise. This exclusion applies to the insured car and any motor vehicle to which coverage may extend under any portion of this policy. This exclusion applies whether or not the excluded drivers have permission to operate the vehicle. The insured agrees to pay the company for any and all sums, costs and expenses incurred by the company if the company becomes legally liable for a loss which is excluded under this agreement. Este acuerdo es válido para las futuras renovaciones, restituciones y cambios en esta póliza, a menos que se notifique por escrito a la compañía de lo contrario. Esta exclusión se aplica a cualquier vehículo automotor y al auto no asegurado al cual se puede extender la cobertura bajo cualquier parte de esta póliza. Esta exclusión se aplica incluso si los conductores excluidos tienen permiso para operar el vehículo. El asegurador acuerda a pagar a la compañía toda suma, costos y gastos en los que incurra la compañía en caso que la misma resulte responsable legalmente por una pérdida excluida bajo este acuerdo. E-11 (06/99)

1. __________________________________________ _________________________ ________________

FULL NAME OF EXCLUDED OPERATOR RELATIONSHIP TO INSURED DATE OF BIRTH NOMBRE COMPLETO DEL OPERADOR EXCLUIDO RELACIÓN CON EL ASEGURADO FECHA DE NAC. 2. __________________________________________ _________________________ ________________

FULL NAME OF EXCLUDED OPERATOR RELATIONSHIP TO INSURED DATE OF BIRTH NOMBRE COMPLETO DEL OPERADOR EXCLUIDO RELACIÓN CON EL ASEGURADO FECHA DE NAC. 3. __________________________________________ _________________________ ________________

FULL NAME OF EXCLUDED OPERATOR RELATIONSHIP TO INSURED DATE OF BIRTH NOMBRE COMPLETO DEL OPERADOR EXCLUIDO RELACIÓN CON EL ASEGURADO FECHA DE NAC. The named insured knowingly takes complete responsibility for communicating to the excluded person(s) the named insured’s decision to exclude the person(s) named, and consents and agrees to the terms of this exclusion. El titular asegurado es enteramente responsable de comunicar a las personas excluidas que ha decidido excluirlas, y acepta y está de acuerdo con los términos de esta exclusión.

X_________________________________________________ ________________________________ Signature/ Firma Date/ Fecha WITNESSED BY / TESTIGO: ____________________________ ________________________________ Agent’s Signature/ Firma del agente Date/ Fecha E-11 (06/99)

AUTOMOBILE INSPECTION REPORT INFORME DE LA INSPECCIÓN TÉCNICA VEHICULAR

Date: Fecha:

Policy #: Nº de póliza:

Insured: El asegurado:

Year/Año:

Make/Model/: Marca/modelo:

VIN/ (VIN):

Mileage/Millaje:

FOR PHYSICAL DAMAGE COVERAGE, visually inspect the vehicle and indicate on the illustration the areas where any damage exists, such as dents, scratches, and rust. Give particular attention to bumpers, windshields, and condition of paint. Provide a written description of any damage in the space provided below. PARA LA COBERTURA POR DAÑOS FÍSICOS, inspeccione el vehículo visualmente e indique en la ilustración las áreas dañadas, como abolladuras, rayones y óxido. Preste especial atención a la defensa, el limpiador y la condición de la pintura. Provea una descripción escrita de todos los daños en el espacio de abajo.

Remarks/Comentarios:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I Certify that there is no other damage than that noted above. Certifico que no existe otro daño que el que se especifica en este documento ______________________________ __________ ______________________________________ _________ Agent’s Signature/Firma del Agente Date/Fecha Insured’s Signature/Firma del asegurado Date/Fecha

PAYMENT SCHEDULE Policy Insured Type Date(s) Personal Auto Date Due Amount Type Premium Payment* Premium Payment* Premium Payment* Premium Payment* Premium Payment* Premium Payment* Premium Payment* Premium Payment* Premium Payment* Premium Payment* Premium Payment*

Total Premium *Payment amounts include any relevant installment fees

ASSURANCE AMERICA INSURANCE COMPANY AUTHORIZATION FOR AUTOMATIC PAYMENT PLAN

AssuranceAmerica Insurance Company is hereby authorized to initiate electronic entries against the checking account identified below. This authorization pertains to payment of premium and any fees due on the insurance policy and any renewals thereof, issued to me (us) by AssuranceAmerica. The financial institution for the checking account listed below is authorized to honor the entries initiated by AssuranceAmerica and to post them to the account listed below. It is understood that AssuranceAmerica can adjust entries to reflect any premium changes including policy renewals. AssuranceAmerica agrees to provide advance notification, in writing, of any change that will increase the amount to be processed from that which was processed in the previous entry. It is agreed that the financial institution or AssuranceAmerica reserve the right to terminate this payment plan and/or their participation herein at any time. It is understood I can discontinue my participation in this payment plan by contacting AssuranceAmerica Customer Service by phone or in writing. To avoid additional entries against my account, my contact must be at least one (1) business day prior to the next Installment Due Date. If my notice is in writing, it is understood that the deactivation will become effective when the company receives the written notice of deactivation and has a reasonable period of time to process the request. It is understood that in addition to the premium due, ALL applicable fees due on the Installment Due Date may be collected by AssuranceAmerica. These fees may include, but are not limited to, Installment fees, NSF fees, Reinstatement fees, and Late fees. It is further understood if AssuranceAmerica is unable to collect the premiums and fees due on the Installment Due Date due to Insufficient Funds or Account Closed, this payment plan will be terminated and the policy changed to the direct billing method. It is understood that participation in this payment program shall in no way alter or amend the provisions of the automobile policy issued by AssuranceAmerica. Authorization for RECURRING ELECTRONIC FUNDS TRANSFER Policy Number:_________________________________________________________________

Insured Name:_________________________________________________________________

Name of Financial Institution:______________________________________________________

Name(s) on Account:____________________________________________________________

_____________________________________________________________________________

Routing/Transit/ABA number:______________________________________________________

Checking Account Number:_______________________________________________________

By signing this authorization for the AUTOMATIC PAYMENT PLAN we agree to its validity and terms. Account holder’s Signature:_______________________________________ Date:___________

Account holder’s Signature:_______________________________________ Date:___________

***IMPORTANT NOTICE*** PLEASE RETAIN A COPY OF THIS CONTRACT FOR YOUR RECORDS AS IT IS THE ONLY

NOTICE OF AUTO CLUB BENEFITS YOU WILL RECEIVE. THIS CONTRACT MUST BE SHOWN FOR SERVICE.

Should you require emergency service, please reference this number when calling Nation Safe Drivers:

(AssuranceAmerica Managing General Agency POLICY # ) NATION SAFE DRIVERS

800 Yamato Road, Suite 100 Boca Raton, FL 33431

TOWING DISPATCH – (800) 745-5791 Producer Code – 14623- Plan B

Customer Service – (800) 338-2680

24 HOUR EMERGENCY ROAD SERVICE* – Service Contract

A. Emergency Road Service: When members’ auto is disabled, NSD will dispatch an emergency service vehicle to your aid, and you are covered for a maximum per disablement for road service, (one claim per every 72 hours). If for any reason road service cannot be dispatched, the member must receive authorization from NSD to use a garage of their choice, and upon presentation of the original paid tow company receipt, the club shall reimburse the member up to the maximum benefit allowed of a maximum of $50 per incident. Emergency Road Service Consists Of: Mechanical First Aid: ANY SERVICE REQUIRING A MINOR ADJUSTMENT (exclusive of parts) to enable a disabled vehicle to proceed under its own power. Tire Service: Changing an inflated spare from mount to wheel. Battery Service: Attempting to start vehicle with a booster battery. Delivery Service: Delivery of an emergency supply of gasoline, oil or water and other accessories and supplies as may be required and available. Cost of materials delivered shall be paid for by the member. B. Towing Service: When a vehicle cannot be started, it can be towed to a destination of your choice by authorized towing service up to 15 miles. C. Locksmith Service: If keys are locked inside the member’s vehicle, NSD will dispatch locksmith for service. If member goes out of network, NSD will reimburse member up to a maximum of $25. D. Map Service: Your membership allows you to request and receive specially prepared maps for travel. Merely call 1-866-294-0934 your toll-free line two weeks in advance of your trip, giving your trip origin and destination. E. Theft Reward: NSD will pay a person, (excluding member’s family or relatives) $500 for information leading to the arrest and conviction of a person for the theft of a member’s vehicle or tagged valuable articles. F. Excessive Claims will be cause for cancellation (Over 5 calls per contract period) Contract covers one claim per every 72 hours.

THIS IS NOT INSURANCE, NOR PART OF AN INSURANCE LIABILITY POLICY. THIS SERVICE CONTRACT DOES NOT COMPLY WITH ANY FINANCIAL RESPONSIBILITY LAW.

IMPORTANT NOTICE

You are applying for an auto club membership (benefits outlined above) and the previous 4 pages are an application for an auto insurance policy.

The insurance company and motor club are separate business entities offering separate coverages and benefits. It is your responsibility to maintain both your insurance policy and your auto club membership. This motor club package can only be purchased in conjunction with a policy issued through AssuranceAmerica Managing General Agency, which only offers automobile insurance. Once an insurance policy is issued and an auto club membership is established, neither the coverage under the insurance policy nor the benefits under the auto club will be conditioned upon the other. Your down payment is a combination of the premium and fees for your insurance application and the membership dues for your auto club membership. Please sign me up in the Nation Safe Drivers Motor Club I understand I cannot hold AssuranceAmerica Insurance and/or Nations Safe Drivers responsible if I don’t purchase these benefits.

_________________ X________________________________________________________ Date Signature of Applicant

NSD – Lloyds - HI App 02/26/07 182

•

Membership Benefits Benefit Option 1

Excess Accident Medical Expense $1,000 Daily In-Hospital Confinement $125per day

Travel Discounts 5% Rent-A-Car Discounts Included

Lost Luggage Protection Included Emergency Cash $100

ALL LIMITS STATED ABOVE ARE AGGREGATE BENEFIT LIMITS Coverage defined applies only to the person whose name is typed on this enrollment form.

PLEASE READ YOUR SYNOPSIS OF BENEFITS CAREFULLY FOR FULL EXPLANATION OF BENEFITS

NATION SAFE DRIVERS TRAVEL PROGRAM ENROLLMENT APPLICATION Nation Safe Drivers; 800 Yamato Road, Suite 100 Boca Raton, FL 33431

FEE TO ENROLL $ ____________________ EFFECTIVE DATE From ________________To __________________

Applicant’s Name ___________________________________ Address ___________________________________________ City __________________ State __________ Zip _________ DOB ____________________ SS# _____________________

Individual Plan Option # 182-H Agency Name ___________________________________ Address ________________________________________ City __________________ State _______ Zip _________

Please enroll me for the travel program. I further

understand that this is an optional coverage.

Signature of Applicant Date

NSD – Lloyds – HI Contract 051403 182

NATION SAFE DRIVERS TRAVEL PROGRAM

As a Member of Nation Safe Drivers, you receive these fantastic Travel Benefits:

TRAVEL Members can take advantage of Nation Safe Drivers complete travel & discount agency, including specially priced tours to popular destinations around the

world. Call toll-free 1-800-447-2901. Please see rate chart to find out what ravel discounts you are entitled to. Benefit Options: Option I – 5%

RENT-A-CAR DISCOUNTS

You will be furnished with discount cards for automobile rentals honored at thousands of locations in the United States and abroad.

LOST LUGGAGE PROTECTION If your baggage is lost by a transportation carrier, follow carefully the “Lost Baggage Claim Procedure” which is customary with the carrier involved. If you are not satisfied with the results, notify us in writing, supplying a copy of your claim check and claim form. We will endeavor to follow up on your claim to

assure a fair settlement.

EMERGENCY CASH In the event your credit cards or cash have been stolen and you are 250 miles from home, call and we will loan you cash to “tide you over.” Theft must be

reported to police department and a police report must be presented prior to loan. Loan must be repaid to Nation Safe Drivers within 30 days of loss. Benefit Options: Option I - $100

HOSPITAL INDEMNITY BENEFITS

FOR AUTO ACCIDENT ONLY (This Plan does not Pay any Benefits for Loss Caused by Sickness and/or Illness)

This is a description of your benefits issued under the Hospital Indemnity Travel Program, underwritten by 100% Certain Underwriters Lloyds, London and issued to Nation Safe Drivers. Your benefit selection amounts are shown below. If no benefit selection is made, Benefit applies only to the Named Member while involved in an auto accident

while driving or riding in a Private Passenger (Pleasure Use Only) Auto only. Policy Exclusions / Limitations will apply. Benefits are not on a per person basis. All limits are aggregate limits.

“named member” means the person whose name appears on the application Benefit “A”: Excess Accident Medical Expense Benefit applies only to the Named Member (and Family, if elected) while involved in an auto accident while driving or riding in a Private Passenger (Pleasure Use Only) Auto only. • Medical Benefit (Benefit stated is an Aggregate Amount): Option I - $1,000 • Benefit is excess over any other valid and/or collectable coverage (i.e. primary auto, health, etc). • Daily In-Hospital Confinement Benefit: Option I - $125 per Day Benefits are payable regardless of any other coverage in force (not on an excess basis). Other restrictions apply: Annual Aggregate: 365 Days; Maximum Recurrent period: none Minimum Confinement Period: One Day; Benefits Start: Day One. The plan will pay the Daily In-Hospital Confinement Benefit amount for each day the Named Member (and Family, if elected) is registered as an In-patient in a hospital if: A) The “named member” is hospitalized as a result of an auto accident only: and B) The “named member” is under a medical doctor’s care; and C) The “named member” is confined for at least the Minimum Confinement Period; and D) The hospital provides at least a full day’s Room and Board; and E) The accident occurs subsequent to the effective date of this membership.

SPECIFIC POLICY EXCLUSION / LIMITATIONS There is no coverage for the following: 1) Any person for:

a) Loss due to suicide or attempted suicide while sane or insane; or b) Intentional or self inflicted injury; or c) Loss that occurs while the covered person is operating any vehicle without the express permission/consent of the registered owner; or d) Loss that occurs while the covered person is driving or riding as a passenger in any vehicle while the vehicle is being driven in any competition, race,

or speed contest; or while being tested in any race track or speedway; or e) For any loss that occurs while the covered person is engaged in any illegal act; or

2) Sickness, illness, disease or bacterial infection of any kind, except: a) as a result of ingestion that is the direct result of the auto related accident; or b) pus forming infections which occur through an accidental bodily injury from the auto related accident; or

3) War or any act of war, whether war is declared or not; or 4) Loss that occurs while the covered person is serving in one of the armed forces of any country or international authority; or

NSD – Lloyds – HI Contract 051403 182

5) Any accident, other than an auto related accident, that occurs while riding and/or driving in a private passenger (pleasure use) auto; or 6) Any claim(s) that appear to be and/or is/are found to be false and/or fraudulent; or 7) Any claim(s) for any services or benefits not shown on this synopsis of coverage; or 8) If the covered person or the driver of the vehicle in which the covered person is a passenger, :

a) Is driving under the influence of any intoxicating liquor(s)/drink(s)/beverage(s) and/or narcotic(s) and/or psychedelic drugs. For purposes of this exclusion, under the influence means that there is any trace of alcohol, narcotics or psychedelic drugs that has been detected by any blood or breath analysis; or

b) Is driving without a valid driver’s license; or c) leaves the scene of an accident (i.e. hit and run). (Note: written police report must be provided by the covered person); or

9) Any accident occurring outside the USA. 10) Any work related accident or any accident that occurs within the course and scope of the covered person’s employment; or 11) Daily in- hospital benefits arising out of the covered person’s confinement in a rehabilitation, convalescent, psychiatric, and/ or nursing home facility.

CLAIMS If a loss should occur, please contact National Adjustment Bureau; 1108 E. Newport Center Drive; Deerfield Beach, FL 33442 and/or #954-596-4880 to request claim forms to file your claim. NOTICE OF CLAIM: Written notice of claim must be given to National Adjustment Bureau within 20 days after a covered loss occurs or begins. If such notice cannot be given during such time then it must be done as soon as reasonably possible. The notice must include your name, the name of the Named Insured, and the member number. It should be sent to National Adjustment Bureau; 1108 E. Newport Center Drive; Deerfield Beach, FL 33442. CLAIM FORMS: Once we receive written notice of claim, we will provide claim forms. You can also obtain claim forms at www.nationaladjust.com. WRITTEN PROOF OF LOSS: Written proof of loss must be sent to us at the address shown above. Proof of loss must describe the incident, extent and the type and date of loss. If the claim is for a continuing loss for which we make periodic payments, the claimant must give us written proof of loss within 60 days after the end of each period that benefits are payable. For any other loss, written proof must be given to us within 60 days after the date of loss. TIME OF PAYMENT OF CLAIMS: We will pay any benefits due within 30 days from the receipt of written proof of loss and any additional documents/paperwork requested/required. Benefits that provide for periodic payment will be paid monthly. PHYSICAL EXAMINATION: We have the right to have you examined by a physician assigned by National Adjustment Bureau. This may be done as often as reasonably required by NAB while a claim is pending or while we are paying benefits. LEGAL ACTIONS: No legal action may be brought unless there has been full compliance with the terms and conditions of this membership. In no case can any action be taken to recover on this membership within 60 days after written proof of loss has been given. No such action may be brought after one year from the time written proof of loss is required to be given. BENEFICIARY DESIGNATION AND CHANGE: The “named member”may choose one or more beneficiaries. Forms may be requested for this purpose. Such forms shall be filed with the holder of the beneficiary records, National Adjustment Bureau. You may change beneficiaries at any time. The beneficiary’s consent is not required unless an irrevocable beneficiary has been named. The change will be effective only upon receipt by the holder and it will take effect on the date you sign it. Any payment made by us in good faith prior to our receipt of any beneficiary change will end our liability to the extent of such payment. SUBROGATION: In the event of any payment made under this membership, Nation Safe Drivers shall be subrogated to all the covered person’s rights of recovery therefore against any person(s) and or/ organization(s). The member shall execute and deliver any and all instruments and papers and do whatever else is necessary to secure such rights. The member shall do nothing to prejudice such rights of Nation Safe Drivers, and benefits will be void if such rights are prejudiced. This description of Hospital Indemnity Benefits is intended to describe the benefits issued to Nation Safe Drivers. Nation Safe Drivers maintains insurance coverage for those benefits. The benefits shown herein may be changed or cancelled in accordance with the provisions of Nation Safe Drivers’ insurance policy. This may be done as result of 1) a change of eligibility of Nation Safe Drivers; or 2) amendment or termination of the policy. A COPY OF NATION SAFE DRIVERS’ INSURANCE POLICY WILL BE MAILED TO THE NAMED MEMBER” UPON WRITTEN REQUEST.

Cancellation This service contract may be cancelled by Nation Safe Drivers by mailing to the Named Member at the address shown on the application, written notice stating when, not less than ten (10) days thereafter, such cancellation shall be effective. The mailing of notice as aforesaid shall be sufficient proof of notice and the effective date and hour of cancellation stated in the notice shall become the end of the contract period. This service contract may be cancelled by the Named Member by surrender hereof and my mailing to Nation Safe Drivers, written notice stating when thereafter such cancellation shall be effective. If Nation Safe Drivers cancels, earned fees shall be computed pro-rata. If the Named Member cancels, he/she shall return membership cards, service contract, personal accident certificates and other papers and documents supplies to him during service period. Earned fee of such service contract shall be computed on an earned as collected basis. Fee adjustment may be made at the time cancellation if effected and if not then made, shall be made as soon as practicable after cancellation becomes effective. The Nation Safe Drivers check or check of its representative mailed or delivered as aforesaid shall be sufficient tender of any refund of fee due of the Named Member.

CUSTOMER SERVICE NUMBER (800) 338-2680

Nation Safe Drivers 1108 E. Newport Center Drive * Deerfield Beach, FL 33442

Bind / Print Policy

Road Runner Contract Application Administered by “Road Runner”

Road Runner Contract Certificate

Administered By “Road Runner”

Certificate Holder: Eff. Date: Term: Fee $

FOR HELP OR CLAIMS CALL TOLL FREE: 1 - (888) 692-5820 (1-88TOWCLUB0)

Vehicles Limits of Liability for Benefits * Agency Name

# Year / Make / Model A B Address, City, State, Zip

$20 PER DAY / 14 DAYS

FAX OR E-MAIL 3 TIMES

This certificate is NOT an Insurance Policy and does NOT comply with ANY Financial Responsibility or No-Fault laws of any State or Territory.

*Benefits Apply To All Vehicles Listed

Name of Applicant: ________________________________________________________ Eff. Date: _____________________________________________________________ Address: _________________________________________________________________ City, State, Zip: ________________________________________________________ Term: (Check) [ ] 6 Mo. [ ] 1 Year Fee: ______________ Agency Name, Address Vehicle (1) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ Vehicle (2) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ Vehicle (3) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ Vehicle (4) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ I hereby acknowledge that I was offered and accepted this optional product, and I understand that this product is not underwritten by the auto insurance carrier. I understand it will be billed monthly unless paid in full at time of contract issuance. Insured Copy Signature: __________________________________________________________

Road Runner Benefits

As a member of Road Runner Motor Club all the benefits listed here are available to you in consideration of the payment of the fee provided in the application. Coverage is extended only to the vehicle listed as the covered vehicle on the application. Your membership will begin on the date shown on the application and will continue for the term shown on the application. All benefits are provided by Road Runner Motor Club, administrative offices at P.O. BOX 14637 Augusta, GA 30919, (706) 210-4794. All benefits and services are described herein and are applicable throughout the United States and Canada. The rental services provided by this contract are guaranteed under a service contract reimbursement policy; the name and address of the insurer of the reimbursement policy is Georgia Mutual Insurance Company 6575 Peachtree Industrial Blvd. Norcross, GA 30092. However we wish to inform you that:

This is not an Automobile Liability or an Automobile Physical Damage Insurance Contract

Benefit A – RENTAL WILL REIMBURSE THE RR CONTRACT CERTIFICATE HOLDER FOR THE ACTUAL COST OF RENTING AN ECONOMY VEHICLE FROM A COMMERCIAL AUTOMOBILE RENTAL FACILITY, AFTER THE FIRST DAY, TO A MAXIMUM OF FOURTEEN (14) DAYS UP TO A MAXIMUM OF THE DAILY LIMIT FOR THE DESIGNATED VEHICLE SHOWN IN THE RR CONTRACT CERTIFICATE. AS A RESULT OF AN ACCIDENT WITH ANOTHER AUTOMOBILE OR ANIMAL WHILE THE RR CONTRACT CERTIFICATE HOLDER WAS DRIVING OR A MEMBER OF THE HOUSEHOLD IF LISTED ON THE INSURANCE POLICY. THERE IS NO COVERAGE WHEN LOSS IS DUE TO THE THEFT OF THE VEHICLE. Benefit B – MAP SERVICE WILL FAX OR E-MAIL MAP QUEST DIRECTIONS 3 TIMES IN A SIX (6) MONTH PERIOD.

Bind / Print Policy

Road Runner Contract Application Administered by “Road Runner”

Road Runner Contract Certificate

Administered By “Road Runner”

Certificate Holder: Eff. Date: Term: Fee $

FOR HELP OR CLAIMS CALL TOLL FREE: 1 - (888) 692-5820 (1-88TOWCLUB0)

Vehicles Limits of Liability for Benefits * Agency Name

# Year / Make / Model A B Address, City, State, Zip

$20 PER DAY / 14 DAYS

FAX OR E-MAIL 3 TIMES

This certificate is NOT an Insurance Policy and does NOT comply with ANY Financial Responsibility or No-Fault laws of any State or Territory.

*Benefits Apply To All Vehicles Listed

Name of Applicant: ________________________________________________________ Eff. Date: _____________________________________________________________ Address: _________________________________________________________________ City, State, Zip: ________________________________________________________ Term: (Check) [ ] 6 Mo. [ ] 1 Year Fee: ______________ Agency Name, Address Vehicle (1) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ Vehicle (2) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ Vehicle (3) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ Vehicle (4) Year: __________ Make: ___________________ Model: __________________ ______________________________________________________ I hereby acknowledge that I was offered and accepted this optional product, and I understand that this product is not underwritten by the auto insurance carrier. I understand it will be billed monthly unless paid in full at time of contract issuance. Agent Copy Signature: __________________________________________________________

Road Runner Benefits

As a member of Road Runner Motor Club all the benefits listed here are available to you in consideration of the payment of the fee provided in the application. Coverage is extended only to the vehicle listed as the covered vehicle on the application. Your membership will begin on the date shown on the application and will continue for the term shown on the application. All benefits are provided by Road Runner Motor Club, administrative offices at P.O. BOX 14637 Augusta, GA 30919, (706) 210-4794. All benefits and services are described herein and are applicable throughout the United States and Canada. The rental services provided by this contract are guaranteed under a service contract reimbursement policy; the name and address of the insurer of the reimbursement policy is Georgia Mutual Insurance Company 6575 Peachtree Industrial Blvd. Norcross, GA 30092. However we wish to inform you that:

This is not an Automobile Liability or an Automobile Physical Damage Insurance Contract

Benefit A – RENTAL WILL REIMBURSE THE RR CONTRACT CERTIFICATE HOLDER FOR THE ACTUAL COST OF RENTING AN ECONOMY VEHICLE FROM A COMMERCIAL AUTOMOBILE RENTAL FACILITY, AFTER THE FIRST DAY, TO A MAXIMUM OF FOURTEEN (14) DAYS UP TO A MAXIMUM OF THE DAILY LIMIT FOR THE DESIGNATED VEHICLE SHOWN IN THE RR CONTRACT CERTIFICATE. AS A RESULT OF AN ACCIDENT WITH ANOTHER AUTOMOBILE OR ANIMAL WHILE THE RR CONTRACT CERTIFICATE HOLDER WAS DRIVING OR A MEMBER OF THE HOUSEHOLD IF LISTED ON THE INSURANCE POLICY. THERE IS NO COVERAGE WHEN LOSS IS DUE TO THE THEFT OF THE VEHICLE. Benefit B – MAP SERVICE WILL FAX OR E-MAIL MAP QUEST DIRECTIONS 3 TIMES IN A SIX (6) MONTH PERIOD.

For Payment Inquiries call: ASSURANCEAMERICA Phone: (770) 952-0200 Toll Free: (800) 450-7857

For General Inquiries contact your agent:

Phone: Fax:

Personal Auto Insurance Premium Due Bill To

Payment Due Date Minimum Amount Due

Insurance Carrier Policy Number Effective Expires

Past Due Amount Installment Due Installment Fee Total Due Pay in Full

Last Payment Information:

If late payment of your policy causes the Company to issue a cancellation notice, a $5 late fee will be charged. Avoid a late fee by getting your payment to the Company or your agent by the due date. Dear AssuranceAmerica Customer: On April 1, 2004 the Georgia Department of Motor Vehicle Safety (DMVS) began sending notices to owners of vehicles registered in the state of GA who (1) do not have mandatory insurance confirmed through Georgia Electronic Insurance Compliance System (GEICS) or (2) have a lapse in maintaining insurance coverage for more than 24 hours. AssuranceAmerica has taken the necessary steps to ensure compliance with the requirements from the DMVS in transmitting vehicle information appropriately. However, should you receive a notice from DMVS, please contact your agent or call our Customer Service Department at 770-952-0200 or 1-888-952-2902. Your vehicle identification number (VIN) on your insurance policy must match exactly with the VIN on your vehicle registration. You have the availability to check on the insurance status with DMVS by going to http://www.dmvs.ga.gov/motor/insurance. Click on Insurance Status Inquiry and then enter your vehicle identification number and your vehicle registration number.

- - - - - - - - - - - - - - - - - - - - - - Detach here and remit with check or money order. - - - - - - - - - - - - - - - - - - - - - -

Payment Coupon for:

Make Check Payable to:

Policy No:

Company:

Payment Due Date

Total Amount Due

Amount Paid

To ensure your payment is correctly applied to your account, return this part with your payment. Be sure to write your policy number on your check.

ed.5/15/2003

Georgia FCRA Notice Thank you for considering AssuranceAmerica Insurance Company as your insurance provider. As part of underwriting your policy, an inquiry has been made with ChoicePoint Services, Inc., our provider of consumer reports. You are receiving this notice, as required by law, because your insurance premium may have been adversely affected by information received from ChoicePoint Services Inc. Based on information available to ChoicePoint Services Inc., a credit score was developed for use in determining your policy premium. The four items listed below were the top four items that most heavily influenced the development of that score.

NCF Reference Number __________________ If you believe any one of these items are an incorrect part of your consumer credit report and you have been adversely affected by information contained in a consumer report provided by ChoicePoint Services Inc., you have the right under the Fair Credit Reporting Act to initiate a dispute. To dispute any items, please contact the ChoicePoint Consumer Credit Dispute Center by calling 1-(866)-323-0932 or write to PO Box 105289, Atlanta, GA 30348-5289 and provide your name, address, date of birth, Social Security Number, and NCF Reference Number on this form.

Once you have been notified your dispute has been resolved and you want to request a new score you may immediately contact AssuranceAmerica Customer Service and request a new score be ordered and have your policy be re-rated back to the effective date of the current policy period. Contact customer service at (888) 952-2902. If you are at an impasse with a credit bureau in correcting your file or you have a life changing or unusual event you may make an appeal by contacting customer service and providing any necessary documentation they may ask for. If granted, your policy will be re-rated back to the current policy period effective date with a neutral or no score rate except in cases where a deceased spouse or other named insured’s credit score results in a lower policy premium. You are also entitled to obtain a free copy of such report(s) from ChoicePoint Service Inc. within 60 days of receipt of this notice. These report(s) must be made available to you within 24 hours of request. To request a credit report, please contact the ChoicePoint Consumer Service Center by calling 1(800)-456-6004 or write to PO Box 105108, Atlanta, GA 30348-5108 or visit www.consumerdisclosure.com.

http://www.consumerdisclosure.com/

Georgia Uninsured Motorist Notice Form

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 liability 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 Required Applicant’s Signature:__________________________ Date:____/____/_____

Alliance HealthCard of Florida, Inc. “A Discount Medical Plan Organization”

_____________________________ Membership Agreement

The __________________is administered by: Alliance HealthCard of Florida, Inc.

3500 Parkway Lane

Suite 720

Norcross, GA 30092

Toll Free number

Effective Date of Membership __________________________ Type of Membership Program __________________________ Term of Membership __________________________

Cancellation of Membership You have the right to cancel your membership at anytime. If you cancel your

membership within 30 days of receiving your membership card and the membership

materials, you are entitled to a full refund of your membership fees. Please notify the

agency where you purchased your membership to obtain any refund due OR please mail

cancellation letter and your private label program membership card to: Private Label

Program, c/o Alliance Healthcard, 3500 Parkway Lane, Suite 720, Norcross, GA 30092.

Renewal of Membership The membership automatically renews unless cancelled by the member.

Disclosures: This Plan is NOT Insurance. The ____________________ provides discounts at certain health care providers for medical services. This discount program does not make payments directly to the providers of medical services. The program member is obligated to pay for all health care services but will receive a discount from those health care providers that have contracted with the discount plan organization. The discount health care benefits of the program include access to a doctor network, vision care network, dental care network, pharmacy network, chiropractic network and a nurse helpline. Membership Phone Directory

Member Services: 1-800-898-4575

General Questions, Request Replacement Card, Recommend New Provider,

Locate Providers, Comment on Provider Services, Member Complaints,

Mail-Order Pharmacy, and 24-Hour Nurse Line

Member Complaints 1-800-898-4575

If you have a complaint, please call Member Services and speak with

a representative. Member Services will either resolve your problem on

the phone or contact you with a resolution after they have reviewed the issue.

I hereby acknowledge that I was offered and accepted this optional product, and I understand that this product is not underwritten by AssuranceAmerica Insurance Company. I understand it will be billed monthly unless paid-in-full at time of contract issuance.

Signed: ________________________________________________ Date: _____________________________________

**Your Alliance Healthcard membership will cancel if your auto insurance premium is not paid as due.

AssuranceAmerica Additional Driver Discovery Disclosure or Exclusion Form

Additional drivers associated with this address were discovered and are listed below. If any listed driver lives in the household or regularly uses the vehicle(s), they must be added to the policy. If a driver is excluded, they may not drive any vehicles insured by this policy. Failure to disclose drivers in the household or allowing excluded drivers to operate an insured vehicle is material misrepresentation and could result in claims denial and/or cancellation of the policy. Check Appropriate Box

Name Date of Birth Not in household Do not know this

person Added to policy*

Named Insured Signature: __________________________________________________________ Date: _________________________________ *If a listed driver is added as “Excluded” please sign a driver exclusion form.

Thank you for considering AssuranceAmerica Insurance Company as your insurance provider. As part of underwriting your policy, an inquiry has been made with ChoicePoint Services, Inc., our provider of consumer reports. You are receiving this notice, as required by law, because your insurance premium may have been adversely affected by information received from ChoicePoint Service Inc. Please note that ChoicePoint did not make any decision regarding your policy premium and is, therefore, unable to provide specific reasons regarding the policy premium determination. However, they can supply you with a copy of your report(s) if you contact:

ChoicePoint Consumer Service Center

P. O. Box 105108

Atlanta, Georgia 30348-5108

(800) 456-6004

www.consumerdisclosure.com

CLUE Reference Number:_______________________

If you have been adversely affected by information contained in a consumer report provided by ChoicePoint Services Inc., you have the right under the Fair Credit Reporting Act to obtain a free copy of such report(s) from ChoicePoint Service Inc. within 60 days of receipt of this notice.

http://www.consumerdisclosure.com/

ASSURANCEAMERICA INSURANCE COMPANY - …rater.accuauto.net/pdf/GA/amaappsp.pdf · PO Box 723128,...

Documents

Transcript of ASSURANCEAMERICA INSURANCE COMPANY - …rater.accuauto.net/pdf/GA/amaappsp.pdf · PO Box 723128,...