J.C. TAYLOR MODIFIED AUTO INSURANCE APPLICATION TOLL FREE HOT RODS ( )

Transcription

1 J.C. TAYLOR MODIFIED AUTO INSURANCE APPLICATION TOLL FREE HOT RODS ( ) Named Insured (Applicant): Date of Birth _ Address: City: State: Zip Code: Home phone number: ( ) _ Occupation: Are you the registered and legal owner of the vehicle(s) you wish to insure? Yes No State Registered If no, explain: Special Registration? I. Vehicle(s) to be insured (complete supplemental vehicle form) Veh. Year Make Model Serial Number Annual Mileage *attach appraisal for vehicles over $30,000 and supply 4 photos of every vehicle. Use separate sheet if necessary. Present Value Odometer Reading II. Driver Information (List all licensed drivers living in household). List all accident and traffic violations for the past three years. Drivers' Name License Number Date of Birth Date of Violation Description of accident or Mo. Day Year Mo. Day Year violation III. Coverage and Rates (Annual policy term & rates apply) The following Coverages are available. (Check limit desired, UM rates vary by state) Bodily Injury and Property Damage Vehicle 1 Vehicle 2 Vehicle 3* Premium Liability $100,000 Single Limit $60.00 $40.00 $20.00 Liability $300,000 Single Limit $80.00 $56.00 $32.00 Medical/Personal Injury Protection $8.00 $6.00 $4.00 Uninsured Motorist (Basic Limit) Above rates apply in most states. Specific state election form may be required. *All units in excess of three NO CHARGE FOR ABOVE COVERAGES. Physical Damage Coverage Premium Comprehensive (Includes Fire & Theft) - $250 Deductible.75 per $ of insurance. Street Rods & Modifieds per $ of insurance. Replicars/Kit Cars/Exotics Collision - $250 Deductible.55 per $ of insurance. Street Rods & Modifieds..85 per $ of insurance. Replicars/Kit Cars/Exotics TOTAL PREMIUM IV. Requested effective date of coverage Policy Minimum Premium - $150 (Subject to state exception) IMPORTANT! SEE OTHER SIDE FOR ADDITIONAL QUESTIONS & SIGNATURE M0233 Ed. 07/05 WEB

2 To properly expedite the handling of your application, please answer the following questions: 1. Annual Mileage: (a) Club functions (b) Other uses Describe 2. Name of Car Club to which you belong: 3. Are your vehicle(s) listed on this application garaged? Yes No 4. Where are the vehicles garaged? (Street, city, state, zip code) 5. Construction of Garage? Cinder Block Brick/Stone Frame Other 6. Any protective devices installed in the garage? Fire Extinguisher Locks Burglar Alarm Sprinkler System Other (describe) 7. Is vehicle in restoration shop at this time? Yes No 8. Are vehicles used in any racing events? Yes No ( explain) 9. Are vehicles currently insured? Yes No Insurance Company 10. Do you own any Antique or Classic vehicles? Yes No If yes, please list policy number for companion policy credit. V. Other Vehicles in Household (Indicate if company car) Veh. Year Make Model Important Notice Regarding The Fair Credit Reporting Act: in making this application for insurance it is understood that as part of our underwriting procedure, an investigative consumer report may be prepared whereby information is obtained through personal interviews with friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics and mode of living. If an investigation is made, you can be assured that it will be handled in the strictest of confidence. If you wish information of the nature and scope on the Consumer Report which may be requested, ask your agent for the address of the Company handling your account. Applicable in Pennsylvania Any person who knowingly and with intent to injure or defraud an insurer files an application or claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000. My vehicle(s) will be used mainly in exhibitions, club activities, parades, and other functions of public interest and will not be used primarily for the transportation of passengers or goods and that all answers and information on this application and any supplements are true and correct. Signature Date NOTE: Your insurance becomes effective upon payment of the entire premium and ACCEPTANCE OF THE RISK by J.C. Taylor only. NO BINDING AUTHORITY. Broker Information (If applicable) MAIL APPLICATION TO: J.C. TAYLOR MODIFIED AUTO AGENCY, INC. 320 S. 69 th STREET UPPER DARBY, PA CHECK LIST ( ) Name Address Phone _ Fax _ I.D.# Signed fully completed application Four color photos Copy of daily use policy (PA,NJ,FL,NY) Check for full premium Appraisal (over $30,000) Broad form DOC Named Individuals if daily cars are Business autos Signed, completed supplemental form Signed state option forms (if applicable) Please answer all questions. Thanks Underwritten by the Foremost/Maryland Casualty Insurance Companies (Members of the worldwide Zurich Financial Services Group with offices and claim facilities in principal U.S. Cities) M0233 Ed. 07/05 WEB

3 J.C. TAYLOR MODIFIED AUTO INSURANCE SUPPLEMENTAL VEHICLE INFORMATION Please estimate the values as best you can for each vehicle being submitted. Applicant: (Please Print) Signature: V ehicle: Date: Engine: Stock Yes No Describe Modifications: Cubic Inches Nitrous Oxide Yes No Body Style: Describe any enhancements & modifications: List any fiberglass parts: Wheels & Tires: Does the vehicle have a roll cage? Yes No Describe any specialty wheels & tires: Exterior Paint: Maximum Limit 40% of the value of the vehicle. Describe any custom paint used: Date last painted? (Mo/Yr) / I accept the maximum limit or exterior paint coverage of 40% of the total vehicle shown below. Interior: Air Conditioner Yes No Power Windows Yes No Sound Equipment Yes No Options & Equipment: Other: List special options & approximate value: * Appraisal required for values over $30,000. * Descriptive bill of sale for recently purchased vehicles. *Total M0234 ED

4 REQUIREMENTS Need 4 color pictures as indicated below Rear Angle View Engine (Hood Open) Interior (Open Door) Front Angle View VEHICLE CONDITION Ratings: 1 = Not Restored 2 = Major Defect 3 = Average Condition 4 = Slight Defect 5 = Show Condition ITEMS EVALUATED Comments Exterior Paint Exterior Body Tires Exhaust System Chrome Trim Wheels Glass Upholstery/Carpets Engine OVERALL CONDITION SIGNATURE: _ DATE: M0234 ED

5 Uninsured, Underinsured Motorists Bodily Injury and Property Damage Coverage Selection Virginia Your policy provides bodily injury and property damage uninsured and underinsured motorists coverage equal to your policy s liability limits. You have the option of selecting coverage limits less than your policy s liability limits, but not less than the state s financial responsibility limits. If you choose to select coverage limits equal to the state s financial responsibility limits, only uninsured motorists coverage will be provided and we will not be obligated to make payment for bodily injury or property damage caused by the operation of an underinsured motor vehicle. Please indicate any optional coverage you desire by completing this form and returning it promptly to the J.C. Taylor Agency. Failure to return this form is your indication that you do not desire optional coverage limits. I hereby select bodily injury and property damage uninsured motorist coverage at the state s financial responsibility limits. I understand that this selection does not include coverage for bodily injury or property damage caused by the operation of an underinsured motor vehicle. $70,000 Combined Single Limit Bodily Injury $25,000 each person/$50,000 each accident, Property Damage $20,000 each accident I hereby select bodily injury and property damage uninsured and underinsured motorist coverage at the following optional limit which does not exceed the liability limits on my policy, nor is less than financial responsibility limits. $100,000 Combined Single Limit $300,000 Combined Single Limit $500,000 Combined Single Limit $1,000,000 Combined Single Limit I understand that my selection applies to all vehicles on my policy, including any additional or replacement vehicles which I may add in the future, unless I request different coverage in writing. Policy number: Date the above selection/rejection is to be effective: Name Insured s signature: Date of signature: M0340 Ed. 5-98