FLORIDA AUTOMOBILE JOINT UNDERWRITING ASSOCIATION (FAJUA)

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1 FLORIDA AUTOMOBILE JOINT UNDERWRITING ASSOCIATION (FAJUA) SERVICED BY: DOVETAIL INSURANCE APPLICATION APPLIES TO: PERSONAL AUTO NAMED NON OWNER MOTOR HOME MOTORCYCLE POLICY Autos with a Manufacturers Suggested Retail Price (MSRP) in excess of $45,000 or $45,000 including customization are not eligible for physical damage coverage. 1. Agency Name Producer s Name Producer s Code Street City State Zip Code Producer s Fax Number ( ) Telephone No. (Incl. Area code) Producer s DFS License Number Producer s Tax Number ( ) 2. Applicant (As shown on motor vehicle registration) Mailing Address Apt. No. City County State In City Exact Location of Residence If No Street Number Used Employer s Name Zip Code Telephone (Inc. Area Code) Home ( ) Business ( ) Place of Principal Garaging Employer s Address State of Motor Vehicle Registration (City, State, Zip Code) 3. VEHICLE DESCRIPTION: VEHICLE - 1 VEHICLE - 2 Year Make Model Name & Body Style Year Make Model Name & Body Style Vehicle Identification Number Length of Motor Home Vehicle Identification Number Length of Motor Home Vehicle Damaged Does vehicle have damaged glass? If Yes, explain in Remarks Is vehicle customized? Vehicle Damaged Does vehicle have damaged glass? If Yes, explain in Remarks Is vehicle customized? Street City State Zip Street City State Zip Business Miles one way to work or school Business Miles one way to work or school Territory Rate Class Points Symbol Age Group Cycle Wt. Territory Rate Class Points Symbol Age Group Cycle Wt. VEHICLE - 3 VEHICLE - 4 Year Make Model Name & Body Style Year Make Model Name & Body Style Vehicle Identification Number Length of Motor Home Vehicle Identification Number Length of Motor Home Vehicle Damaged Does vehicle have damaged glass? If Yes, explain in Remarks Is vehicle customized? Vehicle Damaged Does vehicle have damaged glass? If Yes, explain in Remarks Is vehicle customized? Street City State Zip Street City State Zip Business Miles one way to work or school Business Miles one way to work or school Territory Rate Class Points Symbol Age Group Cycle Wt. Territory Rate Class Points Symbol Age Group Cycle Wt. Application Submission Procedures All applications for insurance (and premium finance agreements when applicable, see Rule 3) must be LEGIBLE and be received at the SERVICE PROVIDER ON A GROSS REMITTANCE BASIS WITHIN TEN (10) BUSINESS DAYS OF ELECTRONICALLY BINDING THE APPLICATION. FAJUA-PP (Edition 4-13 AIPSO Revision) 1

2 5. COVERAGES: Equal Limits Of Liability Must Be Purchased For All Vehicles BODILY INJURY LIABILITY $100,000/$300,000 Maximum PROPERTY DAMAGE LIABILITY $50,000 Maximum NAMED NON OWNER BI AND PD (ONLY) (No Coverage for Owned or Acquired Autos) PERSONAL INJURY PROECTION NOT APPLICABLE FOR MOTORCYCLES AND NONOWNERS No Deductible or Deductible of $250 $500 $1,000 Applicable to: Named Insured or Named Insured and Dependent Resident Relatives OPTIONS TO ELIMINATE PIP BENEFITS FOR: Work Loss Named Insured or Named Insured and Dependent Resident Relatives MEDICAL PAYMENTS $10,000 $500 $1,000 $2,000 Motorcycles Only COMPREHENSIVE (Autos with an MSRP in excess of $45,000 or $45,000 including customization and motorcycles with an MSRP in excess $20,000 or $20,000 including customization are not eligible for physical damage coverage.) Deductible of $250 $500 $1,000 COLLISION (Same limit as Comprehensive) Deductible of $250 $500 $1,000 Anti-lock Braking System Discount Airbag Discount Anti-theft Device Discount Motorcycle (Maximum $20,000 MSRP) Deductible of $250 $500 $1,000 Customized Value (Rule 37 and Page 3 of Application) $ (Maximum MSRP plus customization not over $45,000 for autos and $20,000 for motorcycles) UNINSURED MOTORIST Stacked Non-Stacked FINANCIAL RESPONSIBILITY FILING CHARGE ESTIMATED PREMIUM PER VEHICLE TOTAL ESTIMATED PREMIUM FLORIDA HURRICANE CATASTROPHE ASSESSMENT AMOUNT SUBMITTED WITH APPLICATION Vehicle No. 1 Vehicle - No. 2 Vehicle No. 3 Vehicle No. 4 Limits Premium Limits Premium Limits Premium Limits Premium 10,000 PAY PLAN ANNUAL FAJUA PAY PLAN 25% down plus $10 Service Fee and applicable Filing Fees. 6 monthly installments with $3 per installment fee. PREMIUM FINANCED (Attach legible Premium Finance Contract, if applicable.) PREMIUM OWED ON PRIOR FAJUA POLICY Does applicant owe the FAJUA a premium for another policy? Previous FAJUA Policy Number Premiums past due must accompany this application in addition to the down payment. See Rule 4. Insured s check for payment returned by a financial institution for Non Sufficient Funds voids the application ab initio (the time and date of the application). 6. ATTACH COPIES OF CURRENT MOTOR VEHICLE RECORDS DATED WITHIN FIFTEEN (15) DAYS OF DATE OF THIS APPLICATION AND CURRENT REGISTRATIONS FOR ALL VEHICLES. 7. OPERATOR INFORMATION: Names of All Operators as Shown on Driver s License and unlicensed residents *MS - Marital Status: S-Single, M-Married, W-Widowed, D-Divorced, SP- Separated Applicant and Other Drivers APPLICANT Relationship to Applicant APPLICANT No.1 % Use of Vehicle No.2 Birth Sex M/F *MS Driver s License No. Occupation Names of Other Residents in Household 13 Years and Over Birth Sex M/F Names of Other Residents in Household 13 Years and Over Birth Sex M/F DRIVER S LICENSE: Has the insured(s) and anyone who usually operates the automobile been licensed for at least three years in the U.S., District of Columbia or Canada? If No, give date of issuance of original license. MATURE OPERATOR MOTOR VEHICLE ACCIDENT PREVENTION COURSE DISCOUNT: If Yes, submit Course Completion Certificate. FAJUA-PP (Edition 4-13 AIPSO Revision) 2

3 8. ACCIDENTS: Has applicant, or named insured and any other person who usually operates the motor vehicle(s) been involved, either as owner or operator, in ANY motor vehicle accident during the thirty-six (36) month period immediately preceding the effective date of this application? If Yes, complete the following. of Accident Place of Accident Degree of Accident Exception Name of Operator Mo/Day/Yr City State Negligence Code % EXCEPTIONS: See Manual Rule 24 for list of nonchargeable accidents and indicate accident exception code if applicable and attach evidence. 9. CONVICTIONS: (MOTOR VEHICLE) Has the applicant, or named insured and any other person who usually operates the motor vehicle(s) been Convicted or Forfeited Bail at anytime during the immediately preceding thirty-six (36) months? If Yes, complete the following (if necessary, use Remarks section). NOTE: A paid ticket or fine is an admission of guilt and therefore constitutes a conviction. Did Conviction of Conviction Place of Conviction Name of Operator Arise As A Result Mo/Day/Yr of a Crash City State 10. FINANCIAL RESPONSBILITY: Is the applicant or other eligible operator required to file evidence of financial responsibility? Type of Filing: Name Owner s (to allow for operation of owned vehicles) Case or File Number Social Security No. Operator s (to allow for operation of non-owned vehicles) State Where Filing Required Both 11. NAMED NON-OWNER: Complete below if this application is for non-owner policy. No Coverage for Acquired Autos. (a) Does the applicant own an automobile? (c) Is a vehicle owned by a member of the household? (b) Will vehicle be operated in applicant s occupation or business See Rule 73 (d) Is vehicle leased? See Rule INSURANCE RECORD: Name of latest carrier Policy No. Termination STACKED UNINSURED MOTORISTS IS AVAILABLE TO INDIVIDUAL NAMED INSUREDS ONLY (SEE RULE 6) 13. FLORIDA UNINSURED MOTORIST COVERAGE SELECTION/REJECTION FORM: YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY. Uninsured Motorist Coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehicles because of bodily injury or death resulting therefrom. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the policy. For the purpose of this coverage an uninsured motor vehicle may include a motor vehicle as to which the bodily injury liability limits are less than your damages. Florida law requires that motor vehicle liability policies include Uninsured Motorist coverage at limits equal to the Bodily Injury Liability limits in your policy unless you select a lower limit or reject Uninsured Motorist Coverage entirely. Please indicate your selection or rejection below. If you do not reject Uninsured Motorist Coverage, your policy will be issued with Uninsured Motorist Coverage for the same limits as your Bodily Injury Liability Coverage. Initials I reject Uninsured Motorist Coverage entirely. I reject Bodily Injury Uninsured Motorists Coverage at limits equal to my Bodily Injury Liability Coverage (split limits) and I select the following lower limits. Select one: Initials Split Limits Initials Split Limits Initials Split Limits Initials Split Limits $ 10,000/20,000 $ 15,000/30,000 $ 25,000/50,000 $ 50,000/100,000 $100,000/300,000 I understand and agree that this selection or rejection applies to my policy of liability insurance and future renewals or replacements of such policy which are issued at the same Bodily Injury Liability limits. If I decide to change my selection or rejection of Uninsured Motorist Coverage, I must let the Company know in writing. % ELECTION OF NON-STACKED COVERAGE (Do not complete if you have rejected Uninsured Motorist) You have the option to purchase, at a reduced rate, non-stacked (limited) type of Uninsured Motorist coverage. Under this form if injury occurs in a vehicle owned or leased by you or any family member who resides with you, this policy will apply only to the extent of coverage (if any) which applies to that vehicle in this policy. If an injury occurs while occupying someone else s vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of uninsured motorist coverage available on any one vehicle for which you are named insured, insured family member, or insured resident of the named insured s household. This policy will not apply if you select the coverage available under any other policy issued to you or the policy of any other family member who resides with you. If you do not elect to purchase the non-stacked form, your policy limit(s) for each motor vehicle are added together (stacked) for all covered injuries. Thus, your policy limits would automatically change during the policy term if you increase or decrease the number of autos covered under the policy. If your policy is a personal auto policy or, if your policy is a commercial auto policy and you are designated as an individual in the Declarations, your policy will include stacked Uninsured Motorists Coverage unless you reject Uninsured Motorists Coverage entirely or you select non-stacked Uninsured Motorists Coverage. If your policy is a commercial auto policy and you are designated as other than an individual in the Declarations, your policy will include non-stacked Uninsured Motorists Coverage, unless you reject Uninsured Motorists Coverage entirely. I hereby elect the non-stacked form of Uninsured Motorist Coverage. I understand and agree that selection of any of the above options applies to my liability insurance policy and future renewals or replacements of such policy which are issued at the same Bodily Injury Liability limits. If I decide to select another option at some future time, I must let the Company know in writing. FAJUA-UM (4-13) X *If you are not an individual, stacking of Uninsured Motorists Coverage is not available. FAJUA-PP (Edition 4-13 AIPSO Revision) 3

4 THIS APPLICATION AND THE ESTIMATED PREMIUM ARE SUBJECT TO THE APPROVAL OF THE FAJUA IN ACCORDANCE WITH RATES, RULES AND FORMS FILED WITH AND APPROVED BY THE FLORIDA DEPARTMENT OF FINANCIAL SERVICES, OFFICE OF INSURANCE REGULATION. THIS INSURANCE IS BEING AFFORDED THROUGH THE FLORIDA AUTOMOBILE JOINT UNDERWRITING ASSOCIATION AND NOT THROUGH THE PRIVATE MARKET. PLEASE BE ADVISED THAT COVERAGE WITH A PRIVATE INSURER MAY BE AVAILABLE FROM ANOTHER AGENT AT A LOWER COST. AGENT AND COMPANY LISTINGS ARE AVAILABLE IN THE LOCAL YELLOW PAGES. 14. BODILY INJURY LIABILITY COVERAGE REJECTION: The law in the state of Florida effective October 1, 1989 requires that you carry both Personal Injury Protection and Property Damage Liability. Bodily Injury Liability coverage will pay for damages for which you become legally responsible because of an auto accident. YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY AND OTHERS USING YOU VEHICLE SHOULD YOU CAUSE PHYSICAL INJURY TO ANOTHER PARTY IN AN AUTOMOBILE ACCIDENT. PLEASE READ CAREFULLY. I hereby acknowledge that my right to purchase all auto coverage in Florida has been explained to me. I acknowledge for myself and for any person who may be operating or responsible for the operation of any vehicle insured herein, the liability coverage for Bodily Injury has been rejected and that this policy does not provide any coverage for the Florida Bodily Injury Financial Responsibility requirements or for the bodily injury law requirements of any other state. If I decide to purchase this coverage at some future time, I must let the insurer know in writing. Bodily Injury Liability Rejection may not be used if the policy is used for Certification of Financial Responsibility. 15. PERSONAL INJURY PROTECTION: I UNDERSTAND THAT I MAY PURCHASE THE FOLLOWING COVERAGE WITH ANY OF THE OPTIONS INDICATED AND RECEIVE A REDUCTION IN PREMIUM. Personal Injury Protection (PIP) is mandatory, but the following options are available to you to prevent duplication with other private plans or benefit programs: Deductible Options: Applies To: Work Loss Options: $250 $500 $1,000 Named insured and dependent resident relatives (NIRR) I elect to exclude work Loss for: Named insured only (NIO) Named insured and dependent resident relatives (NIRR) Named insured only (NIO) For Personal Injury Protection insurance, the named insured may elect a deductible and exclude coverage for loss of gross income and loss of earning capacity ( lost wages ). These elections apply to the named insured alone, or to the named insured and all dependent resident relatives. A premium reduction will result from these elections. The named insured is hereby advised not to elect the lost wages exclusion if the named insured or dependent resident relatives are employed, since lost wages will not be payable in the event of an accident. In accordance with the provisions of Florida Insurance Code, section which requires insurers to offer certain limitations to Personal Injury Protection coverage, the undersigned insured does hereby request the limitations indicated below to the Personal Injury Protection coverage to be provided by the policy for which I/we are applying. Complete the information below for Dependent Relatives and Other Members of the Household. Submit MVRs for all dependent relatives. Birth Driver s License No. or FL ID No. Dependent Resident Relative Name Relation to Applicant (if 16 years of age or older) NAMED DRIVER EXCLUSION: A named insured may elect to have a driver excluded from the personal auto insurance policy provided (1) the driver/operator is not the named insured or resident spouse and (2) the excluded driver/operator is an owner of a registered motor vehicle. I authorize the person(s) listed below to be excluded from my insurance policy. This means that none of the coverage, except Personal Injury Protection and Property Damage Liability afforded by the policy, will apply to any damage, losses or claims of any persons or organization caused while any motor vehicle insured by this policy is being used or operated by the excluded driver(s) listed below. In the event that this policy is certified as proof of financial responsibility, coverage for Bodily Injury Liability will be afforded if included in the Declarations. Coverage for claims arising under Property Damage Liability arising from an accident or loss that occurs while a vehicle is being operated by the excluded driver(s) shall be limited to $10,000. This exclusion applies regardless of any provisions in the auto policy defining insured persons. I understand that this agreement will be binding and will apply to all future renewals, reinstatements, and changes in my policy unless I notify you otherwise. This application must be accompanied by copies of (1) current vehicle registrations and (2) Florida driver s licenses for each excluded driver shown below. Any excluded driver without a Florida driver s license must not have a suspended license and must provide a copy of Florida ID Card. Complete the information below for Excluded Drivers of the Household (To exclude more drivers, attach a separate sheet or use the driver exclusion form) Birth Florida Driver s Excluded Driver s Name Florida ID Card No. Vehicle Registration No. Relation to Applicant License No This endorsement applies to the person(s) listed above, regardless of whether or not the same person(s) is/are listed under the OPERATOR INFORMATION section of this application. FAJUA-PP (Edition 4-13 AIPSO Revision) 4

5 17. APPLICANT S STATEMENT REGARDING HOUSEHOLD RESIDENTS AND LICENSED DRIVERS: 1. I have listed all residents of my household on this application for insurance in the section titled OPERATOR INFORMATION. 2. I understand that resident(s) include any and all persons 13 years or older who reside full or part-time at the applicant s residence including any and all student(s) living away from home within the state of Florida, and person(s) in the Armed Services stationed within the state of Florida. This definition of residents applies to both the Operator Information and Driver s License sections of this application for insurance. 3. I have listed all persons age 13 or older who are licensed on this application for insurance in the section entitled Operator Information. 4. I understand that persons licensed includes any and all persons 13 years or older who are licensed and are students living away from home within the state of Florida, and persons in the Armed Services stationed within the state of Florida. 5. I understand the person(s) licensed includes any and all person(s) 13 years or older who are licensed, who are full or part-time residents of the applicant s residence whether or not they are operators of the vehicle(s) listed. 6. I understand the person(s) licensed includes any and all person(s) 13 years or older who are licensed, who are full or part-time residents of the applicant s residence and are not operators of the vehicle(s) listed. 7. I have listed on this application for insurance all operators who have a driver s license or learner s permit and who reside in my household. 8. I understand that operators include those person(s) that currently have their driving privileges restricted, suspended, or revoked or are not licensed and drive my vehicle(s). 9. I acknowledge my responsibility to immediately add to my policy, by signed endorsement, anyone in the future that becomes eligible as an operator as described above. 10. I acknowledge my responsibility to notify the FAJUA service provider, by signed endorsement, of anyone in the future that becomes a resident of my household and that may be eligible for the benefits if involved in an accident. 11. I affirm that I reside at the address given on this application for insurance at least ten (10) months out of each year. I fully understand that my failure to comply with any of the above may cause my policy to be null and void and could result in the denial of any claim. The FAJUA service provider may deny the claim on the basis of material misrepresentation. Pursuant to F.S (1)(b), any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of a claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. I have read and understand all of the above stated information. 18. APPLICANT S STATEMENT: In compliance with the Fair Credit Reporting Act, you are hereby notified that an investigative consumer report may be made through personal interviews with neighbors, friends, associates or other persons concerning the character, general reputation, personal characteristics and mode of living of any person proposed for insurance. Upon written request, additional information as to the nature and scope of their report will be provided. You may request to be interviewed if an investigative consumer report is prepared in connection with this application. You also have a right to receive a copy of the investigative consumer report upon written request. Applicant - Please initial here It is also hereby agreed and understood that misrepresentation of a material fact on this application may cause this coverage to be declared null and void as of the effective date (F.S ). Pursuant to F.S (1)(b), any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. The coverages, including the offer of additional coverages, were explained to me and I knowingly made the selections on this application. Further, I understand rejection of any coverage above applies with respect to all vehicles now insured under the policy as well as any vehicle which may be covered by the policy in the future regardless of whether it is owned by me on the date of execution of this application for insurance. The above-signed rejections will apply to any renewal, additional vehicle endorsement, replacement vehicle endorsement or to other supplemental coverage to the policy, with the exception of Uninsured Motorist Coverage which may be endorsed onto the policy (if in force) at any point in the future, subject to endorsement provisions in the underwriting guidelines. I (we) hereby agree to pay any and all premiums due on the policy to be issued. I further understand that the total premium shown in the Coverages Section of this application is the producer s calculation based in part upon the assumption that the information that I have provided regarding my driving record, designation and information concerning other operators of the insured vehicle and their driving records, and the principal location of the insured(s) is accurate and complete. If the FAJUA service provider determines that any such information is inaccurate or incomplete, I will be notified of any additional premium based on accurate and complete information. I agree to pay such additional premium according to the directions in such notice, or to cancel my policy in accordance with F.S I agree that if my initial premium remittance to the FAJUA or to the producer is not honored by my financial institution, the application is voided ab initio (as of the date and time of the application) and no coverage will be afforded. I have read and understand all of the above stated information. I hereby acknowledge that I have explained the available coverages from the FAJUA, applicable deductibles and options to the applicant. Producer s Signature FAJUA-PP (Edition 4-13 AIPSO Revision) 5

6 19. BINDER PROVISION: When the Producer binds coverage, a binder number, date and time of binding is automatically added to this application. The FAJUA agrees to hold bound the limits and coverage specified in this attached application of the insured named herein, such application being completed, duly executed and accepted by the Producer, subject to the following conditions: A. This binder is in effect for a period not to exceed sixty (60) days from the effective date stated herein. The coverage provided by this binder will terminate immediately upon: (a) The issuance of the policy applied for, or (b) The issuance of any policy affording similar insurance, or (c) 60 days from the effective date provided by electronic binding, or (d) 60 days from receipt of the application at the servicing carrier if not electronically bound. B. A premium charge will be made for this binder if the policy, when bound, is not accepted by the insured. C. The insurance bound hereunder shall be subject to all the terms and conditions of policy forms FAJUA (PERSONAL AUTO) or CA (COMMERCIAL AUTO). D. This binder shall not exceed Bodily Injury Limits of $100/$300 and Property Damage Liability Limits of $50,000 or Combined Single Limits of Liability of $300,000. (Note: Higher limits may be required and retroactively approved to the effective date of the binder.) E. Autos with an MSRP in excess of $45,000 or $45,000 including Customization and Motorcycles with an MSRP in excess of $20,000 or $20,000 including Customization are not eligible for physical damage coverage. APPLICANT S STATEMENT I declare to the best of my knowledge and belief that all statements contained in this application are true and that these statements are offered as an inducement to the Company to issue the policy for which I am applying. I understand that my producer is not authorized to file proof of Financial Responsibility or Certificates of Insurance on my behalf to any third party. THIS POLICY IS SUBJECT TO AUDITS AND/OR INSPECTIONS X X Producer s Signature X Print Producer s Name Coverage may not be bound except by electronic binder. Electronic Binder Number Binding and Time SSN Florida Automobile Joint Underwriting Association company code REMARKS The Following Must Be Submitted With The Application: Application Signed and d by Applicant and Authorized FAJUA Producer Annual Premium Payment or Deposit Premium if on FAJUA Pay Plan, or Premium Finance Contract, when Applicable Copies of Florida Driver s Licenses or Florida ID Cards for all dependent resident relatives 16 years of age or older. Motor Vehicle Driving Records of the Applicant and all Operators d Within Fifteen (15) Days prior to the of this Application Copies of current Vehicle Registrations or Temporary Registrations and Bills of Sale If Applicable, The Following Must Also Be Submitted With The Application: Completed Legible Auto Inspection Form(s) and Two (2) Photos of the Vehicle(s) Copy of Vehicle Lease Proof of Customization Bill of Sale for Customization d no more than Thirty (30) Days Prior to Binding Driver Training Certificate Mature Operator Course Certificate Excluded Driver with a registered vehicle: Copies of Florida Driver s License and current Vehicle Registration Excluded Driver without a registered vehicle: Copy of Florida ID Card Excluded Driver without a Florida Driver s License and without a suspended Florida Driver s License: Copy of Florida ID Card Producers may not issue Certificates of Insurance, Binders, ID cards or other forms of insurance evidence on behalf of the FAJUA. FAJUA-PP (Edition 4-13 AIPSO Revision) 6

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