INFORMATIONEN (nicht per )

Transcription

1 INFORMATIONEN (nicht per )

2 Der Versicherungsschutz: Bei Campingfahrzeugen ist Teil/Vollkasko nicht möglich. Wer wird versichert: Was wird versichert: Versicherungsdauer: Prämien: Antrag: Police: Schäden: Fahrzeugkauf in den USA: Wichtig: Es wird keine Police erstellt bei Reisebeginn in: Kanada, Alaska, Idaho, Indiana, Kansas, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Tennessee, Vermont, West Virginia, Wyoming, Wisconsin. Der angebotene Versicherungsschutz gilt nicht in Mexico! Grundsätzlich obliegt die letzte Entscheidung, ob die Police erstellt oder der Antrag abgelehnt wird, dem Versicherer in USA.

3 Coverage to be effective:! Name of Applicant: Date of Birth: Mailing Address: Marital Status: Phone Number: International Driver s Licence No.: Authorized Driver: Description of Vehicle to be insured: Coverage Options: Liability $ Comprehensive & Collision $ $ $ $ $ 250$ 500 $ 250$ 500 Visited Countries: Please sign by hand! Bitte per Hand unterschreiben!

4 I fully understand and agree: Hiermit bestätige ich:

5 ! JA NEIN

6 ! JA NEIN Bitte immer beifügen: Benötigen Sie die Police nicht für ein ganzes Jahr, senden Sie uns oder unserer Agentur bitte eine Kündigung per , die folgenden Inhalt haben muss: Beispiel: I (Name) herewith cancel my policy (Nr). effective. (Datum). because I have to return to Europe. Please refund to my address: (Name und Heimat-Anschrift)

7 THE SUNRISE GROUP QUOTE REQUEST FOR AUTO INSURANCE PROGRAM Phone: (800) Fax: (386) FORM INFORMATION (Please Print or Type) First Name: M. I. Last Name: Date of Birth: / / Home Country Address: USA Address: Occupation: Telephone: (Home) Work: USA entry visa type: Policy #: Driver s License # : Date of original license / / Expiration Date: / / MM/ DD/ YYYY MM/ DD/ YYYY State/country Licensed: Prior insurance: Pol#: How many years with Prior Insurance Carrier: Marital Status: Countries to be visited: Mail Policy to: [ ] APPLICANT [ ] ALTERNATE ADDRESS: VEHICLE INFORMATION Vehicle # I Type of Vehicle: [ ] Automobile [ ] Motorhome [ ] Motorcycle Year: Make: Model: Present Value: US $ Vehicle Identification Number (VIN) Vehicle Usage: (Select one) Pleasure Work <15 miles Work >15 miles Business Length of Motorhome: (Ft) License Plate No. and State Registered: CC of Motorcycle: Name & Address of Loss Payee: Vehicle # 2 Type of Vehicle: [ ] Automobile [ ] Motorhome Year: Make: Model: Present Value: US $ Vehicle Identification Number (VIN) Vehicle Usage: (Select one) Pleasure Work <15 miles Work >15 miles Business Length of Motorhome: (Ft) License Plate No. and State Registered: Name & Address of Loss Payee: COVERAGE INFORMATION Effective Date: [ ] Package A: (Liability, Comprehensive, Collision) [ ] Package B: (Liability & Comprehensive only) [ ] Package C: (Liability Only) If your vehicle is over 20 years old, only Package C is available. Non US Citizen Quote Request 10/12v

8 PAGE 2 The Following Information is required for all additional operators: First Name: M. I.: Last Name: Relationship to Insured: Date of Birth: / / Driver s License #: Occupation: Date of original license / / Expiration date: / / State Licensed: First Name: M. I.: Last Name: Relationship to Insured: Date of Birth: / / Driver s License #: Occupation: Date of original license / / Expiration date: / / State Licensed: First Name: M. I.: Last Name: Relationship to Insured: Date of Birth: / / Driver s License #: Occupation: Date of original license / / Expiration date: / / State Licensed: ADDITIONAL INFORMATION 1. Have you or any driver listed above been involved in more than one motor vehicle accident or had a violation in the past 3 years? 2. Have you or any driver listed above had automobile insurance declined or cancelled in the past 3 years? YES NO 3. Are you or any driver listed above less than 25 years of age or over 75 years of age? ( a medical statement is required if over 75)? 4. Does the described vehicle(s) have any cracked or broken glass or other safety deficiency? 5. Do you or any driver listed above have a physical or mental deficiency or impairment? 6. Have you or any driver listed above had a license revoked, suspended or refused? 7. Are you or any driver listed above employed in or have a permanent residence in the USA or Canada? 8. Are you or is any driver listed above a USA or Canadian citizen? 9. Is your permanent residence or the residence of any driver of this vehicle within 100 miles of the USA/Mexico border? 10. Is the vehicle(s) registered in Louisiana, Massachusetts, New Jersey, South Carolina or North Carolina? 11. Is the vehicle valued at more than $70,000? 12. Is the vehicle(s) considered a sports car or high-performance vehicle? 13. Is the vehicle(s) rented or borrowed? I hereby warrant the truth of the above statements, and declare that I have not withheld any information whatsoever which might tend to influence the acceptance of this application. I understand that any false statement by me will constitute a breach of warranty and cause the policy to be void. I agree that this application shall be the basis of the Policy between the Company(s) and me. I understand that the policy expires after the period of coverage stated on this form ends and coverage is effective only after the application and full premium payment are received by the Company, or at a later date if specified. Signature of Applicant Date Signed Non US Citizen Quote Request 10/12v

9 Für Zahlungen per Kreditkarte füllen Sie bitte das Formular aus und übersenden es per Post oder per Fax an:! Angaben zum Karteninhaber Verwendungszweck: Rechnungsbetrag in : Angaben zur Kreditkarte Bitte nicht per senden!