License # Filing Type. Conviction Date. Vehicle Identification Number (VIN) Body Type. Interest Type Name / Address

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1 Old American County Mutual Fire Insurance Company P.O. Box 9030 Addison T T Auto Insurance Application Policy : Named Insured: Jimmie Matthews Today's Date: 2/4/20 Effective Date/Time: 2/4/20 at 05:56 p.m. Expiration Date/Time: 06/4/202 at 2:0 a.m. Term: 6 Month Named Insured Jimmie Matthews Producer d8-d0-d0 Co-Insured Name Name Insurance Plus Address Drv Name Jimmie Matthews 890 Vantage Point Dr Dallas, T Phone Address Birth Date 03/02/973 License Address: 2555 Inwood Rd, Ste 247 City, State, Zip Dallas T Phone License State T Gender Male Marital Status Never marr Relation to Insured Applicant Social Security First Licensed 2/989 Drv License Status Valid US License Driver Status Rated/Licensed SR Req Filing Type Drv Conviction Date Type of Violation or Accident Veh Year Make n Owner Policy Model Body Type Vehicle Identification Number (VIN) Garaging Zip Bus Use Veh Rating Symbol or Value BI/PD MP/PIP CP/CL Veh Interest Type Name / Address Discount/Surcharge Name nowner Disc/ Surch Disc Discount/Surcharge Name Disc/ Surch Vehicle Additional Equipment Including Make & Model Cost/Value Coverage Name Limits/Deductibles Premium (w/ discounts) Veh Veh 2 Bodily Injury Liability $30,000 Each Person $60,000 Each Accident Property Damage Liability $25,000 Each Accident Premium Total Per Vehicle Applicable Charges Policy Fee $66.00 Total Premium: $27.00 Total Down Payment: $46.7 TPOL0003_

2 Policy : Named Insured: Jimmie Matthews Today's Date: 2/4/20 APPLICANT QUESTIONS Have you listed every member of your household age 5 and older, whether licensed or unlicensed, and all regular operators (frequent or infrequent), including those away at school or in the military? Except for students away at school, do all rated drivers reside within the state for at least 0 months of the year and are all listed vehicles garaged within the state for at least 0 months of the year? Have you disclosed all driving record incidents within the last three years for each rated driver, including violations, at-fault accidents and not at-fault accidents, and have you disclosed all losses for each vehicle? Is any rated driver's license currently suspended, revoked or cancelled or had any rated driver been convicted of a motor vehicle felony, vehicular manslaughter or vehicular reckless homicide within the last five years? Have you ever been convicted of insurance fraud or denied coverage for material misrepresentation? Is any rated driver currently being treated (or have they been treated in the past 3 years) for a physical or mental condition (e.g., epilepsy, heart conditions, etc.) that might affect their ability to operate a motor vehicle safely? Are there vehicles in the household, whether owned by you or other that you have not listed on the application? Are any listed vehicles titled to a corporation or other entity that is not a natural person? Is there a salvage or rebuilt vehicle listed that has not been registered for road use? Is any listed vehicle titled/co-titled or owned by someone other than the applicant or co-applicant? Are any listed vehicles used for business, farm, delivery (e.g. newspapers, pizza, groceries, etc.), transportation of people or goods for a fee, or are any listed vehicles frequently driven by (or regularly made available to) individuals other than the drivers listed? Is any listed vehicle used for racing, police or emergency response, taxi service, rental (to others) transportation of explosives/flammables, snowplowing or as a residence? Have any listed vehicles been modified for appearance or performance, including but not limited to the addition of performance enhancing parts or any other modification making it not street legal? Are any listed vehicles grey market, show cars, rare, classic, antique, high-profile or limited production models, or do any listed vehicles use alternative energy sources (flex fuels and hybrids are acceptable) or have more or less than 4 wheels (dual rear-wheeled pickups are acceptable)? TPOL0003_

3 Policy : Named Insured: Jimmie Matthews Today's Date: 2/4/20 REJECTION OF UNINSURED / UNDERINSURED MOTORIST COVERAGE I understand and acknowledge that Uninsured / Underinsured Motorist, Bodily Injury and Property Damage Coverages (UM/UIM) has been explained to me. I have been offered the options of selecting UM/UIM limits equal to my liability limits, selecting UM/UIM limits lower than my liability limits or rejecting UM/UIM entirely.. I reject Uninsured / Underinsured Motorist Bodily Injury and Property Damage Coverage in its entirety. 2. I reject only Uninsured / Underinsured Motorist Property Damage Coverage in its entirety. The rejection indicated above shall apply to this policy and to all future renewals of this policy, and to any endorsement because of a change in vehicle or coverage, or because of any rewrite, reassurance, or reinstatement of this policy, unless I notify the Company in writing that thereafter Uninsured / Underinsured Motorist Coverage is desired. Applicant / Insured's Signature: Date: 2/4/20 TPOL0003_

4 Policy : Named Insured: Jimmie Matthews Today's Date: 2/4/20 REJECTION OF PERSONAL INJURY PROTECTION I understand and acknowledge that Personal Injury Protection coverage has been explained to me and I have been offered this coverage. If I have rejected this coverage, my signature appears below. Applicant / Insured s Signature: Date: 2/4/20 TPOL0003_

5 Policy : Named Insured: Jimmie Matthews Today's Date: 2/4/20 FRAUD WARNING Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of fraud and may be prosecuted. Further, in the event that the insured commits fraud in a submission of a claim to the company under the policy, the company reserves the right to deny the claim, and to pursue all remedies available under the law. BILLING PRACTICES, NSF PROCEDURE AND FEE DISCLOSURE I understand and agree that I will be liable to reimburse the Company for all costs and expenses incurred, including but not limited to collection agency fees that are related to the collection of outstanding premium amounts due to the Company. If my check or credit card payment is returned or rejected for any reason, I expressly authorize my account to be electronically debited for the amount of the check plus a processing fee up to the maximum allowed by law. This check recovery policy shall have no impact on any cancellation or non-renewal date and time of which I shall be advised. Further, any payments made on my policy will be applied to any fees owed first and then to any premium owed. I understand and agree that if the bank does not honor a check or credit card payment when presented as down payment, the policy is null and void and no coverage shall be afforded. If the bank does not honor any installment payment made by check or credit card, my policy of insurance will be cancelled or non-renewed as if that payment had never been tendered. Further, the Company has the right to make charges related to dishonored checks or credit card payments. I further understand that the Company may charge fees related to the payment plan I have chosen, including but not limited to installment fees, late fees, reinstatement fees and fees relating to dishonored payments. A schedule of such fees will be made available upon request. Any and all fees are in addition to any premium, are fully earned and are not refundable. CONSUMER REPORT DISCLOSURE In connection with this application for insurance and with respect to any renewal or updates related thereto, I recognize that the Company may () make a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living; (2) obtain certain consumer reports (which may include driving record, driver history, claims, credit or household information) or other personal or privileged information from third parties; (3) in certain circumstances, disclose such information, as well as other personal or privileged information subsequently collected by the Company to third parties; (4) review my credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. I grant the Company the authority to perform the foregoing. I also realize that the Company may use a third party to collect information or develop an insurance score. Upon my written request, additional information as to the nature and scope of the report, if one is made, will be provided to me. TPOL0003_

6 Policy : Named Insured: Jimmie Matthews Today's Date: 2/4/20 APPLICANT STATEMENT I understand and agree that I have selected the coverages and limits of liability listed on the application. The Company shall rely on the contents of this application in issuing any policy of insurance or renewal thereof. I acknowledge my responsibility to inform the company of any changes to the information provided in this application. I also understand that payment of premium is defined as being only when the premium payment check or credit card payment has cleared, and no temporary or other coverage of any kind exists unless the bank honors the check when initially submitted by the Company or its agent. I have read this application and hereby declare the foregoing statements and answers to the questions to be true, correct and accurate to the best of my knowledge and belief, and I understand, recognize and agree that said answers are given and made for the purpose of inducing the Company to issue to me the policy for which I have applied. The Company has relied on the statements set forth in this application as the basis on which to issue a policy of insurance. Such policy may be NULL and VOID if such information is false, misleading, or would materially affect acceptance of the risk by the Company. ADDENDUMS TO APPLICATION THAT REQUIRE APPLICANT SIGNATURE: ne Applicant's Signature Producer s Name: Insurance Plus Date/Time: 2/4/20 05:56 p.m. PRODUCER STATEMENT I hereby certify that to the best of my knowledge, all information contained in this application is complete, accurate and correct. I also certify that all questions on the application have been answered by the applicant, that the responses provided are those of the applicant who has signed this application in my presence, and that no coverage was bound by the producer until the application was completed and signed by the applicant. Further, a complete copy of the application has been given to the applicant and the producer has retained a duplicate signed copy. Producer s Signature Producer s Name: Insurance Plus Date/Time: 2/4/20 05:56 p.m. PROY STATEMENT I hereby make application for insurance to the Old American County Mutual Fire Insurance Company. I hereby appoint the President and Secretary of the Company, or their successors in office, with full power in either to appoint or substitute, to be the undersigned's lawful proxy and attorney in fact, and said attorney is hereby authorized and empowered to attend any policyholder meeting, or any adjournment or adjournments thereof, and to represent, vote and otherwise act for the undersigned in the same manner and with the same effect as if the undersigned were personally present. This proxy shall continue in force for the full period of the policy and any renewal thereof, unless sooner revoked in writing and shall be irrevocable for the full period permitted by law. I agree to be governed by the provisions of Chapter 92, Texas Insurance Code. Applicant's Signature Date/Time: TPOL0003_

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