ARIZONA AUTO INSURANCE APPLICATION. Nevada General Insurance Company UNDERWRITTEN BY NEVADA GENERAL INSURANCE COMPANY Transmittal Date/Time:

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1 ARIZONA AUTO INSURANCE APPLICATION Nevada General Insurance Company Transmittal Date/Time: Policy Number: Program: Valu APPLICATION INFORMATION Named Insured and Mailing Address PRODUCER Producer Code Producer Phone # Garaging Address (If Different from Mailing Address) POLICY INFORMATION Effective Date/Time: Insured Expiration Date/Time: Payment Plan: Telephone # (Home) Telephone # (Mobile) Telephone # (Work) Vehicles in Household Months in Residence DRIVER, DEPENDENT, AND HOUSEHOLD RESIDENT INFORMATION All residents and dependents of your household must be listed as drivers or excluded. List the name of each driver exactly as shown on Driver s license. Any individual, other than the named insured or spouse, may be excluded. # First Name Middle Name Last Name Relationship to Applicant DOB Gender Marital Status Living with Spouse Prev State/Prev License (Including International) # Date First Licensed Total Years Licensed Licensed Number State Occupation Rated AZ US Total Int'l Vehicle Miles to Work FR Filing # Employer Employer Address, City, State, Zip Months Employed Work Phone Number AZS100

2 DRIVING HISTORY The following is a complete list of all accidents, Comprehensive claims greater than $500, and traffic violations for all drivers in the past 36 months. All accidents are considered At-Fault unless proof is provided showing Not At Fault (Acceptable proof includes Police Report, CLUE Report or other Carrier s payment). Driver Incident Incident Date DESCRIPTION OF THE AUTOMOBILE(S) # Yr Make Model V.I.N Purchase Date Usage New/ Used State ISO Liab ISO Comp ISO Coll Odometer Reading # Estimated Annual Mileage Garaging Zip Vehicle Type Credits/Discounts Vehicle Surcharges LOSS PAYEE (Financial Institution Only) # Name Address City State Zip Leased Vehicle OPTIONAL AND/OR SPECIAL EQUIPMENT All optional or special equipment either installed by the original manufacturer or the selling vehicle dealership at the time of purchase, must be included on this application. Total not to exceed $500 for stereo equipment. Vehicle # Items(list), Make/Model, I.D. # Required Cash/Value AZS100

3 COVERAGE AND LIMITS OF LIABILITY (Coverage applies only where premium is indicated) Policy Fee TOTAL POLICY PREMIUM PREMIUM PAYMENT INFORMATION PAY PLAN INSTALLMENT FEES TOTAL POLICY PREMIUM DOWN PAYMENT AMOUNT REQUIRED PAYMENT METHOD AMOUNT REMITTED UNDERWRITING INFORMATION Y N EXCLUDED DRIVER INFORMATION (A properly completed and signed exclusion form must be executed.) First Name Middle Name Last Name Date of Birth Relation to Application NON-LICENSED RESIDENTS List all children living in the household (include birth dates) younger than 15 ½. Children age 15 ½ or older must be listed as a driver or excluded. First Name Middle Name Last Name Date of Birth Relation to Applicant DISCOUNTS & SURCHARGE INFORMATION Prior Carrier Name Prior Policy # Months Insured w/ Prior Carrier Prior Liability Limits Days Lapse Total Household Comp Claims >$500 Total # Not-At-Fault Accidents For All Rated Drivers AZS100

4 ATTACHMENTS (List all accompanying documents) Y N The following documents are required to be maintained in the Producer s file and available for review by Nevada General when requested. Arizona Auto Insurance Application. Electronic Payment Plan Form. Driver Exclusion Form. Uninsured and Underinsured Motorists Coverage Selection Form. Applicant's Statement: I have read all of the above application for a Nevada General Insurance Company Auto Policy and I hereby declare that the statements contained herein are true and complete to the best of my knowledge and belief. I agree to pay any surcharge applicable under Nevada General rules which are necessitated by inaccurate statements. This application is submitted to Nevada General with the knowledge that it will be used as the factual basis for the decision of Nevada General to insure, or not to insure me. By signing the application, I acknowledge that I am aware that if at any time it is discovered that any of the statements of fact contained in the application are false, or a material fact is omitted or misrepresented, the policy will be rescinded and declared void at the sole option of Nevada General. Nevada General will provide liability coverage to the extent required by the financial responsibility laws of the state of Arizona for an accident occurring before any policy is declared void. I agree to reimburse Nevada General for any payment made by Nevada General for this liability coverage. All coverages and optional coverages, including Special Equipment Coverage, were explained to me and I fully understand them. I knowingly make the coverage selections indicated. I expressly understand that all coverages under this policy are inoperative and void when the vehicle(s) covered under this policy are used in any way in the insured s or driver s occupation or business unless such use is indicated on the application. I fully understand and agree that coverage is bound no earlier than the time and date the application is electronically bound in Nevada General s system and the application is signed by both me and a broker. I agree that if I pay my initial premium by check or electronic payment, the coverage afforded by this policy is conditioned on the check being honored by the bank when presented for payment. If the check is not honored, it will be deemed non-payment of the premium, and no coverage will have been bound, or afforded under this application and subsequent binder or policy. Signing this application does not bind Nevada General to complete the insurance. I understand that a service charge of $25.00 will be assessed to the balance due on my policy if my bank does not honor any check offered in payment. Imposition of such charge shall not deem Nevada General to have accepted the check unconditionally. I understand that I will be charged a $40.00 cancellation fee if I cancel this policy for any reason. I also understand that the amount of the cancellation fee will be determined in accordance with Nevada General s underwriting rules in effect at the time the policy is canceled. The fee is in addition to any premium Nevada General has earned for the coverage provided by this policy and may be deducted from any refund due to me or added to any outstanding balance owed by me to Nevada General for any unpaid premium and/or fees. I also understand that payment options other than paid-in-full include an installment fee, and late fees or reinstatement fees if a payment is received after the premium due date. Any portion of this application filled out by an agent is expressly acknowledged to have been done at my request. I acknowledge that I have received a copy of this application. I agree to inform Nevada General of any changes in condition (address, drivers, and/or use) within 10 days of such change and vehicle changes within 72 hours of such change, and to accept the resulting premium adjustment. I understand and agree that as part of Nevada General s policy issuance procedure, Nevada General may obtain consumer reports or personal or privileged information from third parties. A routine inquiry will be made to obtain underwriting, claims, and driving record information for all drivers of the vehicle(s) being insured. I authorize Nevada General to obtain such information. Pursuant to Arizona Revised Statutes, Section (D), I am advised that, as part of Nevada General s underwriting procedure, an inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. As part of this inquiry: (1) Personal Information may be collected from persons other than the individual or individuals proposed for coverage; (2) The information, as well as other personal or privileged information subsequently collected, may in certain circumstances be disclosed to third parties without authorization; (3) A right of access and correction exists with respect to all personal information collected; and (4) Arizona Revised Statutes, Section (C) sets forth a more detailed notice, which will be furnished upon request. >>>>> Signature of Applicant X Date: IMPORTANT WINDSHIELD & GLASS REPLACEMENT I understand that I am required under my insurance policy to contact Nevada General (800) before a covered car is repaired. This is so that Nevada General is able to inspect and appraise the damage to the covered car before its repair or disposal. My failure to contact Nevada General before the covered car is repaired will result in my being personally responsible for any unnecessary or unreasonable expenses or costs incurred for the repair of the covered car. >>>>> Signature of Applicant X Date: LIABILITY COVERAGE LIMITS FOR HOUSEHOLD MEMBERS If the Named Insured under this policy or that person s spouse, or any relative (as that term is defined in the policy) sustains bodily injury in an accident, liability coverage under this policy for that bodily injury is limited to the minimum amount of coverage required by the Arizona Financial Responsibility Act. AZS100

5 >>>>> Signature of Applicant X Date: Producer Statement: I hereby represent and certify that the information contained herein is correct to the best of my knowledge; that I have asked the applicant and recorded his/her answer to all questions on this application; that this application was completed and then signed by the Insured-applicant; that a completed copy hereof has been given to the insured-applicant; that I have a duplicate signed copy hereof; and that I am legally qualified to submit this application on behalf of the applicant. >>>>> Signature of Producer X Date: AZS100

6 AGENCY POLICY SUPPORTING DOCUMENTS-Stonewood AZ Valu Program NEVADA GENERAL INSURANCE COMPANY Transmission Date/Time: 10/4/ :14:12 AM Applicant Name: Chris Fountas Policy Number: AZS Agency Name: Freeway Insurance Services of AZ, Inc. Producer Code: AZ Producer Phone: The attached documents are part of this application for insurance. The producer is required to hold them on file as part of the application and provide them to Nevada General upon request. Signed application. Signed Arizona Reduced Coverage Disclosure Form. Signed Power of Attorney (Authorization to Release Vehicle(s) Signed Arizona Uninsured Motor Vehicle Coverage Rejection / Selection Form (always mandatory). Discount Documentation (i.e., Prior Insurance, Good Student, AAA membership, Mature Driver, Safe Driver etc.) Signed Driver Exclusion Form. Copy of Foreign/International license. Photos of vehicles requesting any physical damage coverage or vehicles with damage. Signed Arizona Automobile Business Use Exclusion form. Proof of non-chargeable accident (only required if not validated via the CLUE report). Police Report is unacceptable as proof of no Bodily Injury. Signed EFT authorization form. AZS114

7 P.O. Box 2528 Rancho Cordova, CA Fax: (916) Toll Free: (888) ARIZONA AUTOMOBILE INSURANCE APPLICATION Applicant: Chris Fountas Enrollment Authorization for Electronic Payment EASY STEPS TO ENROLL IN OUR ELECTRONIC PAYMENT PLAN: Complete the enrollment information below to authorize us to pay all future payments from your account. Attach a voided check from your account Electronic payment will begin with the next installment due. A $25.00 fee will be charged for any failed Electronic Payments and you will be removed from EFT. To: Stonewood Insurance Services I authorize you to pay premium from my account on the policy listed on this form. I request that this premium be withdrawn on the scheduled due dates. I request that this authorization continue to apply to any renewal or endorsement later made on my policy. Policy Number AZS Your Name (Please Print) Chris Fountas Your Signature _ AUTHORIZATION TO DRAW PREMIUM FROM MY ACCOUNT and Request for Participation in the Electronic Payment Plan. I agree that this authorization in no way affects the terms of the policy, other than the method of paying the premium; and I understand that, if you are not paid within the time required by the policy, as by the withdrawal being dishonored, or any other reason, then my policy will lapse for non-payment. I understand applicable fees may apply as stated in the application. This authorization will continue in force until this authorization is revoked. Either you or I may terminate this authorization by written notice mailed to the other party. Stonewood Insurance Services must receive written notice of change or termination at PO Box 2528 Rancho Cordova, CA or by fax , at least seven days in advance of the next scheduled withdrawal. DETAILS OF PAYMENT Your Financial Institution Name and Address Bank Name Street Address _ City, State & Zip Type of Account: Checking Transit Routing Number Savings Bank Account Number Please contact your bank for correct account information. Attach Voided Check Here AZS-ACH02

8 NEVADA GENERAL INSURANCE COMPANY AUTHORIZATION TO RELEASE VEHICLE (S) Policy Number: AZS This Authorization to Release Agreement is made effective 10/4/ :14:02 AM. Vehicle(s) Covered by this Release: 2004 Cadillac DEVILLE 1994 BMW 325I 1995 Honda CIVIC DX In accordance with the terms of your policy under Part IV Damage to Covered Car: Adjustment and Payment of Loss, Provision 2.e.: I, Chris Fountas, hereby grant the power, right and ability to Nevada General Insurance Company and its employees and assigns the right to release, move and transfer the above listed vehicles on my behalf and without any additional communication from me. I hereby release the body shop, service center or other service provider of any liability for such release. Signature of Applicant: _ Date: AZS107

9 NEVADA GENERAL INSURANCE COMPANY COMMERCIAL, BUSINESS AND PROFESSIONAL USE Policy#: AZS Named Insured: Chris Fountas I represent and warrant that the vehicle(s) listed below to be insured by Nevada General Insurance Company is (are) NOT used commercially, or in a business or professional endeavor. Year Make Model 2004 Cadillac DEVILLE 1994 BMW 325I 1995 Honda CIVIC DX I fully understand and agree that the insurance to be extended on the policy applied for shall not benefit either the insured(s) or a third party claimant when the vehicle(s) for which coverage is requested is (are) used commercially, or in a business or professional endeavor. I further understand and agree that there will be NO INSURANCE COVERAGE IN FORCE from Nevada General Insurance Company on the policy hereby applied for if I, or any person using the vehicle(s) for which coverage is requested, and (is) involved in an accident while using the vehicle(s) in the course of any commercial, business or professional endeavor. Signature of Applicant: _ Date: AZS108

10 P.O. Box 2528 Rancho Cordova, CA Fax: (916) Toll Free: (888) REDUCED COVERAGE DISCLOSURES THIS POLICY HAS REDUCED OR LIMITED COVERAGES AND IS NOT LIKE A STANDARD POLICY IT IS VERY IMPORTANT YOU READ AND UNDERSTAND THE FOLLOWING AZS Racky Mayugi NAMED DRIVERS ONLY (no permissive use). The policy you have purchased contains limited coverage in that there is no coverage for damage for your car if any person other than the named insured and drivers listed on the declarations page drive your car. This means that if someone else is driving your car, with or without your permission, and there is an accident this insurance policy will not afford any coverage for damage to your car, and any claim made against the policy for such damage will be denied. For damage to your car, this policy only covers the named insured on the car listed and all drivers listed on the Declarations Page all other people in the world are excluded drivers. See Part IV for policy provisions. I understand that I was offered to remove this restriction for an additional premium and I elected not to purchase the coverage. See Important Notices and Warnings in the policy. NAMED VEHICLE ONLY (listed vehicle(s) only). This policy does not give you coverage if you drive any vehicle not listed on the declaration page. In other words, if you drive another vehicle this policy will provide NO insurance of any kind relating to any liability created while driving that vehicle or coverage for that vehicle. I understand that I was offered to remove this restriction for an additional premium and I elected not to purchase the coverage. See Policy Exclusion and Limitations in the policy. TRIPLE DEDUCTIBLE DURING FIRST 60 DAYS AFTER POLICY INCEPTION OR REINSTATEMENT WITH LAPSE, REWRITE WITH LAPSE OR RENEWAL WITH LAPSE OR GAP IN COVERAGE. During the first 60 days after the inception date of this policy and the first 60 days after the effective date of any reinstatement, rewrite or renewal with a lapse or gap in coverage, the deductible listed on the Declarations is tripled. For example, this means if you have a $600 deductible listed and you have a claim within 60 days of any of these events the deductible will be $1,800. See Part IV for policy provisions. NO CASH OUT PROVISION. This policy does not have cash out provision. This means that if you have a covered loss, the policy will cover repairs only and we will not send you a check for the damage amount. In other words, we will only make covered payments to a body shop for actual repairs to your vehicle. Only if your car is deemed a total loss by us will we make payments directly to you. See Part IV for policy provisions. NO RENTAL CAR REIMBURSEMENT COVERAGE. any form for any reason. This policy does not provide reimbursement for a rental car in NO RENTAL CAR COVERAGE. This policy does not provide coverage for a rental car in any form for any reason, except for the Uninsured/Underinsured Motorist Coverage you have selected in your application. NO PAYMENT FOR STORAGE AND TOWING. Except as required by law, this policy does not cover storage or towing costs in the event of a covered loss. This means that you are responsible for any and all storage and towing costs. See Part IV for policy provisions. I understand that I was offered limited storage and towing coverage for an additional premium and I elected not to purchase the coverage. 96 HOUR NOTICE REQUIREMENT FOR NEW VEHICLES. You must notify us to add any additional cars to the policy within 96 hours of the purchase by means of an endorsement and paying the premium. You must also notify us to add any replacement car to the policy if you want car damage coverage to apply to that car. This means that if you purchase another car there will be no coverage after 96 hours unless you notify us to specifically endorse the car to the policy and you pay the premium for the coverage. LIMITED PAYMENT FOR STORAGE AND TOWING. Except as required by law, this policy provides no more than $100 for storage costs and no more than $100 for towing costs in the event of a covered loss. This means you are responsible for any storage costs in excess of $100 and any towing costs in excess of $100. See Part IV for policy provisions. AZS128

11 NEVADA GENERAL INSURANCE COMPANY UNINSURED AND UNDERINSURED MOTORIST COVERAGE SELECTION FORM This endorsement form is a part of policy number AZS Issue to: Chris Fountas You have the legal right to purchase both Uninsured and Underinsured Motorist Coverages with the proposed automobile liability policy. These coverages protect you, your resident relatives, and your passengers. Liability coverage does not in most cases. Uninsured Motorist Insurance provides protection for bodily injuries caused by a negligent motorist who has no insurance or cannot be identified. Underinsured Motorist Coverage provides protection if a negligent motorist has insurance in an amount less than the minimum amounts required by the financial responsibility laws of Arizona, or does not have enough liability insurance to pay for the bodily injuries caused. For a more detailed explanation of these coverages, refer to your policy. This policy will provide Uninsured/Underinsured Coverage in the same amount as the policy s Bodily Injury Liability Limit unless you select a lower amount or no coverage, as stated in this notice. You have the right to purchase both Uninsured Motorist Coverage and Underinsured Motorist Coverage in any amount from $15,000/$30,000 (split limits) up to your policy s liability limit, or you may reject the coverage entirely. Neither may exceed your liability coverage limits for Bodily Injury. The stacking or the combining of coverages selected for each vehicle on this policy to determine the total amount to be paid is not permitted. I understand this policy does not provide stacking or combining of coverages (Initial here) Uninsured and Underinsured Motorist Limits Selection and Cost The Bodily Injury Limits I have selected are $15,000 / $30,000. At these limits, the cost of Uninsured Motorist Bodily Injury for all vehicles in my policy is $ At these limits, the cost of Underinsured Motorist Bodily Injury for all vehicles in my policy is $ I select Uninsured Motorist Bodily Injury limits $15,000 / $30,000 at a cost of $ I select Underinsured Motorist Bodily Injury limits $15,000 / $30,000 at a cost of $ I do not wish to purchase Uninsured Motorist Coverage (Initial Here) I do not wish to purchase Underinsured Motorist Coverage (Initial Here) In signing and dating this Supplement, I acknowledge that I have been offered Uninsured and Underinsured limits equal to the Bodily Injury limits of the policy. I have selected the limits shown above and in the Application. I understand and agree that selection of any of the above options shall be binding on all persons insured under the policy, and that this selection shall apply to any renewal, reinstatement, substitute, amended, altered, modified, or replacement policy with this company or any affiliated company, unless a named insured revokes this selection or selects a different option. Signature of Applicant _ Date AZS110

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