AMERICAN SOUTHERN HOME INSURANCE COMPANY (080) FLORIDA MOTOR HOME APPLICATION

Transcription

1 AMERICAN SOUTHERN HOME INSURANCE COMPANY (080) FLORIDA MOTOR HOME APPLICATION DRIVER INFORMATION Quote/Binder # Policy Number Renewal of Policy # SUBPRODUCER CODE AGENCY CODE SUBPRODUCER: AGENCY NAME: Ramsgate Insurance ADDRESS: ADDRESS: 250 East Park Avenue -- Lake Wales, FL PHONE: PHONE: Fax: APPLICANT INFORMATION LIENHOLDER INFORMATION LAST FIRST MI NAME ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP JOINT OWNER NAME WORK PHONE HOME PHONE ADDRESS ( ) ( ) CITY STATE ZIP GARAGE LOCATION (if different than address above) POLICY PERIOD: 12:01 AM STANDARD TIME STREET EFFECTIVE EXPIRATION CITY STATE ZIP DRIVER NAMES OF ALL BIRTH DATE SOCIAL SECURITY DRIVER'S LICENSE NUMBER POTENTIAL DRIVERS MO DAY YR NUMBER NUMBER STATE DRIVER RELATION MARITAL % NUMBER TO INSURED STATUS SEX USE OCCUPATION DESCRIPTION OF MOTOR HOME LENGTH NEW / DATE ANNUAL YEAR MAKE/MODEL/MODEL NUMBER TYPE IDENTIFICATION NUMBER (FT.) USED PURCHASED MILES VALUE 1. Is the unit ever used in business? No Yes 2. Is the unit ever rented or loaned to others? No Yes If yes, please explain 3. Is the unit owned by persons residing in separate households? No Yes If yes, please explain 4. Has the principal operator owned and operated motor homes for less than 12 months? No Yes 5. Residence 6 months or more/year? No Yes 6. Has insurance been cancelled, declined or non-renewed during the past 5 years?? No Yes If yes, please explain LIST ALL TRAFFIC LAW CONVICTIONS, ALL ACCIDENTS (WHETHER OR NOT AT FAULT) AND ANY LOSS FOR ALL DRIVERS IN THE PAST 3 YEARS. DRIVER NUMBER TYPE OF OCCURRENCE OCCURRENCE DATE EXPLANATION $ DAMAGE INJURY? DESCRIPTION OF TRAILER YEAR MAKE/MODEL/MODEL NUMBER VALUE USE OF TRAILER 7. Is the unit ever used to commute to work or school? No Yes 8. Is the motor home a van conversion or non-professional conversion of a school or public transit bus, step van, pick up or delivery vehicle? No Yes 9. Is the unit a professional conversion? No Yes 10. Is the unit a freightliner-type tow vehicle used to tow anything other than a 5 th wheel travel trailer? No Yes 11. Is there any broken glass or physical damage to the unit and/or miscellaneous trailer? No Yes If yes, please explain 12. Is there any operator with a physical or mental impairment that would affect their ability to safely operate the unit? No Yes If yes, please explain 13. Is the unit titled in a business name or corporation? No Yes 14. Does any operator require a Financial Responsibility Certificate (SR22)? No Yes 15. Has any operator had their driver's license suspended in the last 60 months? No Yes 16. Is the unit registered or garaged outside of the United States? No Yes 17. Is the unit held for sale or on consignment? No Yes 18. Have there been any collision, fire, liability, and/or theft loss(es) within the last 36 months OR a total loss to any vehicle? If yes, please explain No Yes 19. Has any operator filed bankruptcy in the last 7 years? No Yes V61-FL (07/04)

2 Coverages: Value $ 1. Other than Collision Deductible options , Collision Deductible options , Bodily Injury Limit Options 50/ / / Property Damage Limit Options 50, , , Subtotal (Coverages 3 through 4) 6. Personal Injury Protection $10,000 Basic $0 Deductible 7. PIP Insured Only Deductible PIP Insured & Relative Deductible , Coordination of Military Benefits Work Loss Included Work Loss Excluded 10. Exclusion of Work Loss Insured Insured & Relative 11. Extended PIP Benefits 80% Work Loss Work Loss Exclusion 12. Added PIP Include Work Loss Exclude Work Loss $10, Subtotal (Coverages 6 through 12) 14. Medical Expense Limit Options $1,000 $2,000 $5, UM Stacked Limit Options 50/ / / UM Non-Stacked Limit Options 50/ / / Towing and Labor Limit Options Reasonable 18. Personal Effects (ACV) Amount $ 19. Replacement Cost Pers. Effects (Must equal PE ACV if selected) Amount $ 20. Emergency Expense 21. Mexico Coverage 22. Settlement Options Actual Cash Value Replacement Cost Agreed Value 23. Accidental Death & Dismemberment 24. Vacation Liability Limit Options 10,000 25,000 50, , Full Timer Limit Options 100/ / Outstanding Prinicipal Loan Balance 27. Diminishing Deductible Deductible Options Trailer Value $ 29. Total Premium DISCOUNTS SURCHARGES Passive Restraint Accidents Sum all Discounts and Surcharges. Apply Total Discounts/ Surcharges % to coverage in Column 2 above. Coverage: Alarm Only Anti-Theft Vin BINDER COVERAGE IS BOUND AGENT INITIAL IS ATTACHED (AMOUNT TO BE NOT LESS THAN 25% OF ANNUAL PREMIUM OR $50, WHICHEVER IS MORE.) Passive Active -15% Driver Side -20% Driver & Pass. -30% Accident Prev. Course Anti Lock 2 A/V 20% DIRECT BILL INFORMATION FULL PAY (100% DOWN) 4 PAY (25% DOWN) CREDIT CARD (Attach Supplemental Form) EZPay (Attach Supplemental Form) AMOUNT INCLUDED INSURANCE FRAUD NOTIFICATION: WARNING: 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. Notice to Applicant: We may make an investigation into your insurability, including securing a motor vehicle report for all persons listed on this application and, if applicable, information as to character, reputation, mode of living and credit history. Information may be obtained through personal interviews with friends, neighbors or others with whom you are acquainted. If an investigation is made it will be handled in the strictest confidence. Information as to the nature and scope of any investigation will be provided to you if you make a written request. Insured's Statement: I declare that all of the statements contained in this application are true and complete. I hereby apply to the Company for an insurance policy as set forth in this application based on these statements. I understand that if any information is false or misleading or would materially affect acceptance of the risk by the Company, the policy will be null and void and claims denied. I understand that the policy will be void from inception if I pay my initial premium by check, and the check is not honored when presented for payment. A service charge of $10.00 will be assessed if any check offered in payment is not honored by the bank. I understand that the coverage as specified in this application will not apply to a motor home I own while the motor home is used in business or rented, leased or loaned for a charge to any organization, or any person other than me, unless Business Use coverage or Personal Rental coverage is indicated on the Declarations and an additional premium is paid. BINDER PROVISIONS: If coverage is bound, the insurance afforded by this binder is subject to all provisions of the policy form as used in the state where the risk is located. This binder expires at 12:01 am on the 31st day after the effective date or (1) immediately on notification of cancellation by the named insured or the Company, or (2) on its effective date if replaced by a policy with the same effective date as the binder. If this binder is not replaced by a policy, the appropriate premium will be charged, but not less than $ A/V 50% Joint Owner 50% Business Use Light 50% Personal Rental 100% Inexperienced Operator 10% Unit <21 ft. 35% Full Timer / Primary Residence 25% $ Youthful Operator 65% Total Discount/ Surcharge % Signature of Applicant Date Time Signature of Agent Date Time Name of Agent (Please Print) License ID# V61-FL (07/04) American Modern Insurance Group 2004

3 MOTOR HOME POLICY COVERAGE OPTION FORM FLORIDA According to Florida Law you must be given the opportunity to choose No-Fault and Uninsured Motorists options with each renewal. Your current coverages are shown on your Declarations Page. If you wish to make a change, simply indicate on this form the coverages that you desire and return it to the agent shown on your Declarations Page. NO-FAULT AUTOMOBILE COVERAGE OPTIONS For personal injury protection insurance, the named insured may elect a deductible and to 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 wage exclusion if the named insured or dependent resident relatives are employed, since lost wages will not be payable in the event of an accident. 1. Basic Personal Injury Protection (PIP) Under Florida Law you are required to carry PIP coverage. This coverage provides for 80% of medical expenses and 60% of Loss of Income. The total limit if $10,000. If you wish to select BASIC PIP ONLY, please check the box at the front of this Item Deductible Options for Basic Personal Injury Protection Deductible options for PIP are available if you select Basic PIP. If you wish to select a deductible, check the appropriate box: $250 $500 $1,000 $2,000 If you select a deductible, indicate to whom you wish it to apply: Named Insured only Named Insured and Department Resident Relative 3. Work Loss Exclusion If you select this item, there is not coverage for loss of income or earning capacity. If you select this option, choose one of the following: Named Insured only Named Insured and Department Resident Relative 4. Extended PIP This provides either: a. 100% of medical expenses with 80% work loss; or b. 100% medical expenses only (work loss for Named Insured and Relative must be excluded in Section 3). You cannot choose Co-ordination of PIP in Section 4 and also choose Extended PIP. Please check the box at the front of this Item 4. if you want Extended PIP. 5. Additional PIP You can elect to have increased Personal Injury Protection above the basic $10,000 limit. In order to have Additional PIP, you must also have Extended PIP (see section 4). Select one of the following additional limits: $10,000 $25,000 $40,000 $90,000 I understand and agree that selection of any of the above options applies to my liability insurance policy and all future renewals or replacements of such policy. If I decide to select another option at some future time, I must let the Company or my agent know if writing. Named Insured: Signed: Policy Number: Date: Over Please V67-FL (10/01) Page 1 of 2

4 REJECTION OF UM OR ELECTION OF REDUCTION OF UM COVERAGE Uninsured Motorists coverage provides for payment of certain benefits for bodily injury or death caused by owners or operators of uninsured motor vehicles. 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 with bodily injury liability limits less than your damages. Florida law requires that automobile liability policies include Uninsured Motorists Coverage at limits equal to the Bodily Injury Liability limits in your policy unless you, in writing, select a lower limit offered by the company, or reject Uninsured Motorist entirely. Please indicate whether you desire to reject Uninsured Motorist coverage entirely, or whether you desire this coverage at limits lower than the Bodily Injury Liability limits of your policy: I hereby reject Uninsured Motorist coverage. I hereby select Uninsured Motorists limits of which are lower than my Bodily Injury Liability limits. 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) Uninsured Motorist coverage. Under this coverage, if injury occurs in a vehicle owned or leased by you or any family member who resides with you, coverage will apply only to the extent that it pertains to that one vehicle in this policy. If any injury occurs while you occupy 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 vehicle for which you are: 1. a named insured; 2. an insured family member; or 3. an 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 not-stacked form, you policy limit(s) for each motor vehicle are added together (stacked) for all covered injures. Thus, you policy limits would automatically change during the policy term if you increase or decrease the number of autos covered under the policy. I hereby elect the non-stacked form of Uninsured Motorists 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 or my agent know if writing. Named Insured: Signed: Policy Number: Date: V67-FL (10/01) Page 2 of 2

5 American Southern Home Insurance Company UNINSURED MOTORISTS COVERAGE SELECTION OR REJECTION UNINSURED MOTORISTS COVERAGE Policy Number: YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PRO- TECTS 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 with bodily injury liability limits less than your damages. Florida law requires that automobile liability policies include Uninsured Motorist coverage at limits equal to the Bodily Injury Liability limits in your policy unless you, in writing, select a lower limit offered by the company, or reject Uninsured Motorist entirely. Please indicate whether you desire to entirely reject Uninsured Motorist coverage, or whether you desire this coverage at limits lower than the Bodily Injury Liability limits of your policy: a. I hereby reject Uninsured Motorist coverage. b. I hereby select Uninsured Motorist limits of which are lower than my Bodily Injury Liability limits. (Do not complete if you have rejected Uninsured Motorist) ELECTION OF NON-STACKED COVERAGE You have the option to purchase, at a reduced rate, non-stacked (limited) Uninsured Motorist coverage. Under this coverage, if injury occurs in a vehicle owned or leased by you or any family member who resides with you, coverage will apply only to the extent that it pertains to that one 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 a 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. 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 or my agent know in writing. Named Insured: (Please Print) Signed: (Named Insured) Policy Number: Date: Signed: FL License Number (Agent) VM4FL (11/03)

6 Policy Number: DRIVER EXCLUSION ENDORSEMENT - FLORIDA You agree that any of the following coverages afforded by this policy: 1. Bodily Injury Liability Coverage, 2 Medical Payments, 3. Uninsured Motorists, and 4. Physical Damage shall not apply to: 1. any vehicle described in this policy; 2. or any other vehicle to which coverage by this policy may be extended; while such vehicle(s) is (are) being: 1. Used, 2. Driven, 3. Operated, 4. Manipulated by, or 5. Under the care, custody or control, with or without permission, by the person named below: NAME OF EXCLUDED DRIVER RELATIONSHIP TO INSURED All other terms and conditions of this policy remain unchanged. The Named Insured attests to acceptance of this endorsement by his (her) signature. Signature/Acceptance of Named Insured Date VRD09 (02/04)