COMMERCIAL APPLICATION CALIFORNIA AUTOMOBILE ASSIGNED RISK PLAN NOTICE: PRODUCER MUST READ THIS STATEMENT BEFORE PROCEEDING IMPORTANT NOTICE Tis policy is not ffctiv until your application is lctronically transmittd to t Plan by your agnt or brokr. T following conditions must also b mt: (1) Bot you and your agnt or brokr must sign and dat a proprly compltd application. (2) Your agnt or brokr must mail your application to t Plan witin two days of its compltion. You may rqust tat your agnt or brokr transmit t documnts in your prsnc to nsur immdiat covrag, providd t abov rquirmnts ar mt. If t abov rquirmnts ar not mt, your covrag will tak ffct t day aftr t Plan offic rcivs your application. You may rqust tat your agnt or brokr notify you wn your covrag is ffctiv. SECTION 1. PRODUCER OF RECORD Producr Last Nam/Agncy Nam Producr First Nam MI Producr DBA Nam Mailing Addrss St./Apt. # City Stat Zip Cod Tax ID or SS # Producr Licns # Tlpon # (inc. ara cod) Fax # (inc. ara cod) SECTION 2. SIGNING PRODUCER (If t producr complting and signing tis application is t producr of rcord, indicat SAME. Last Nam First Nam MI Signing Producr Licns # SECTION 3. APPLICANT NAME Last Nam First Nam MI DBA Nam Slf Employd? Strt Addrss St./Apt. # City Stat Zip Cod Mailing Addrss St./Apt. # City Stat Zip Cod Hom Tlpon # (inc. ara cod) Businss Tlpon # (inc. ara cod) Tax ID or SS # Businss of Applicant/Natur of Opration Hadquartrs of Opration SECTION 4. OWNERSHIP AND CONTROL OF APPLICANT'S ORGANIZATION Namd insurd is a: Corporation Partnrsip Sol Propritor Otr Managmnt, Ownrsip and Control (List nams of principals and anyon wit mor tan a 10% ownrsip intrst.) Prsidnt: ic Prsidnt: Scrtary: Trasurr: Gnral Managr: Otrs: List all affiliatd companis: Stat of Incorporation Dat of Incorporation Dat actual oprations commncd Dat in Position Snd original, signd application wit cck/mony ordr and rquird attacmnts to: California Automobil Assignd Risk Plan PO Box 7917 San Francisco, CA 94120-7917 Prcnt Ownrsip AIP 1251 CA COMMERCIAL APPLICATION Pag 1 (Rv 09/06)
SECTION 5. OPERATOR INFORMATION List all full-tim, part-tim, and any otr oprator tat usually drivs a vicl. Last Nam First Nam MI Birt Dat MM/DD/YY TOTAL NO of OPERATORS: Drivr s Licns # Stat Ar tr any principal oprators 55 yars of ag or oldr wo av succssfully compltd a Matur Drivr Improvmnt Cours approvd by t California DM? If Ys attac a copy of t crtificat attsting to suc succssful compltion. For applicants wit mor tan four oprators, all additional oprators must b listd on an AIP 3502 Supplmntal Oprator Scdul and maild wit t original application to t Plan. SECTION 6. ACCIDENTS Has applicant, or anyon wo usually drivs t applicant s vicl(s), bn involvd, itr as ownr or oprator, in ANY motor vicl accidnt during t past THIRTY-SIX monts? If Ys, complt t following. Nam of Oprator Accidnt Dat MM/DD/YY Cod* Plac of Accidnt City Stat Bodily Injury or Dat $ $ $ $ *Accidnt Cods 1. Applicant's motor vicl lawfully parkd. 2. Damagd by "Hit and Run" drivr and accidnt rportd to polic witin 24 ours from tim of accidnt. 3. Applicant rimbursd by or on balf of prson rsponsibl for t accidnt or as judgmnt against suc prson. 4. Otr prson involvd in accidnt was convictd. Applicant or oprator was not convictd. 5. Polic or Fir Dpartmnt or First Aid Squad rsponding to an mrgncy call. 6. Otr typ of accidnt - non-cargabl undr provisions of t Plan. Dscrib accidnt in spac providd blow. SECTION 7. CONICTIONS Prop. Damag (incl. your own) Amount Has t applicant or anyon wo usually drivs t applicant s vicl(s) bn CONICTED or FORFEITED BAIL at any tim during t immdiatly prcding THIRTY-SIX monts? Convictd Forfitd Bail If Ys, for itr itm, complt t following. NOTE: A paid tickt or fin is an admission of guilt and trfor constituts a conviction. Nam of Oprator Dat of Conviction or bail forfitur Mo./Day/Yr. SECTION 8. COMMODITIES TRANSPORTED Spcify goods transportd in all vicls: Did Conviction Aris as a Rsult of an Accidnt? Idntify any azardous matrials, wast or substancs bing auld: Natur of Conviction Plac of Conviction City Stat Pnalty Points Pnalty Points Was Licns Suspndd or Rvokd? Idntify radius of oprations. Numbr of straigt-lin, air mils from garaging to furtst dstination to wic vicl travls in on dirction. Includ t % of trips in ac radius class (Must qual 100%). 0 50 Mils % 51 200 Mils % 201 + Mils % Routs (bot outgoing and rturn): Trips From Plac of Origin To Plac of Dstination % of Rvnus # of Trips pr icl pr Mont Principal Citis ntrd Commoditis Carrid AIP 1251 CA COMMERCIAL APPLICATION Pag 2 (Rv 09/06)
SECTION 9. EHICLE INFORMATION AND USE For long distanc, list citis in wic vicls oprat TOTAL EHICLES # Yar icl Idntification # Trad Nam Modl # Typ (1) Garag Location (City/Stat/Zip Cod) Nam of Rgistrd Ownr of icl Wr vicl is prmittd to oprat. Load Capacity (2) Stat of Rgistration Rating Trritory (3) Typ of Rgistration Rating Classification Orig. Cost nw (4)or Rating Symbol Gross icl Wigt (GW) TRUCKS ONLY Gross Comb. Wigt (GCW) Trucks-Tractors only Siz (L-M-H-EH-HT- EHT) Spc Industry (M-T-FD-SD- WD-F-D-C-L-O) For Siz Bus. Rad. (L-I-LD) Final Rating Sating Capacity Tank Capacity How v. is licnsd List all citis troug and in wic vicls oprat. Loss Pay Nam Loss Pay Addrss Loss Pay City, Stat, Zip Cod 1 2 3 4 5 (1) Typ - Truck=T, Truck-Tractor=TT, Trailr=TR, Smi-Trailr=ST, Public Auto=PA (2) Truck-Typ vicls wit Privat Passngr or Combination rgistration and load capacitis of 1500 pound or lss ar ligibl for Basic Rparations Bnfits covrag. (3) For public automobils, us t igst ratd trritory wr t vicls pick up or discarg passngrs. (4) Cassis and Body including Spcial Equipmnt. For applicants wit mor tan fiv vicls, all additional vicls must b listd on a Supplmntal icl Scdul and maild wit t original application to t Plan. SECTION 10. COERAGES AND PREMIUMS (As providd by t Ruls of t Plan.) All vicls writtn undr t sam policy sall av t sam Limits of Liability. Cck appropriat boxs to indicat limits/dductibls. Bodily Injury/Proprty Damag Combind (CSL) icl 1 Est. Prm. icl 2 Est. Prm. icl 3 Est. Prm. icl 4 Est. Prm. icl 5 Est. Prm. Bodily Injury $15,000/$30,000 Proprty Damag $5,000 Otr Otr Uninsurd Motorists BI $15,000/$30,000 Otr Uninsurd Motorists - PD (PPA's only) $3,500 Otr Employr s Non-Ownrsip Covrag (Complt Sction 10.c. if rqustd) Hird Car Covrag Annual Cost of Hir: $ Mdical Paymnts (PPA's only) $1,000 Estimatd Total Prmium pr vicl $ $ $ $ $ Total Estimatd Prmium for vicls 1 5 $ Total Estimatd Prmium for supplmntal vicls $ Total Estimatd Prmium for all vicls $ NOTE: BI AND PD LIMITS WILL BE ISSUED AT MINIMUM FINANCIAL RESPONSIBILITY LIMITS AS REQUIRED BY LAW FOR THE RISK INSURED. AIP 1251 CA COMMERCIAL APPLICATION Pag 3 (Rv 09/06)
SECTION 10.a. COERAGE FOR ACTS OF UNINSURED MOTORISTS: CALIFORNIA DELETION OF COERAGE: T California Insuranc Cod rquirs an insurr to provid uninsurd motorists covrag in ac bodily injury liability insuranc policy it issus covring liability arising out of t ownrsip, maintnanc, or us of a motor vicl. Tos provisions also prmit t insurr and t applicant to dlt t covrag compltly or to dlt t covrag wn a motor vicl is opratd by a natural prson or prsons dsignatd by nam. Uninsurd motorists covrag insurs t Insurd, is or r irs or lgal rprsntativs for all sums witin t limits stablisd by law, wic suc prson or prsons ar lgally ntitld to rcovr as damags for bodily injury, including any rsulting sicknss, disas, or dat, to t insurd from t ownr or oprator of an uninsurd motor vicl not ownd or opratd by t Insurd or a rsidnt of t sam ousold. An uninsurd motor vicl includs an undrinsurd motor vicl as dfind in subdivision (p) of Sction 11580.2 of t Insuranc Cod. REDUCTION OF COERAGE: T Uninsurd Motorists provisions also prmit t insurr and t applicant to agr to provid t covrag in an amount lss tan tat rquird by subdivision (m) of Sction 11580.2 of t Insuranc Cod but not lss tan t financial rsponsibility rquirmnts. DAMAGE TO YOUR EHICLE: (Tis provision Applis Only to Privat Passngr icls Tat Ar Subjct to Commrcial Assignmnt) In addition, t California Insuranc Cod rquirs insurrs to offr covrag for damag to your vicl causd by an uninsurd motor vicl to t xtnt tat you, t insurd party, ar lgally ntitld to rcovr from t ownr or oprator of t uninsurd motor vicl. Suc proprty damag covrag will itr: (1) pay t collision dductibl on t insurd motor vicl, if it is covrd by collision insuranc, or (2) pay for damag to t insurd motor vicl, if it is not covrd by collision insuranc. Tis covrag will not pay for damag to prsonal proprty otr tan t vicl or for loss of us of t vicl, and it will not xcd t smallst of any t following: (1) T amount of t collision dductibl; (2) t actual cas valu of t insurd motor vicl; or (3) $3,500. You may rjct uninsurd motorist covrag compltly or rjct it only wn an insurd motor vicl is opratd by a natural prson or prsons tat you dsignat by nam. If you rjct uninsurd motorist covrag for bodily injury, you must also rjct uninsurd motorist covrag for proprty damag; owvr, you may lct to obtain uninsurd motorist bodily injury covrag witout obtaining uninsurd motorist proprty damag covrag. ALL RISKS: It sall b prsumd tat an application for a policy of bodily injury liability insuranc containing uninsurd motorist covrag if an amount lss tan tat rquird by Insuranc Cod Sction 11580.2, Subdivision (m), signd by you (t namd insurd) and approvd by t insurr, sall b a valid agrmnt as to t amount of uninsurd motorist covrag to b providd. SECTION 10.b. REJECTION OF UNINSURED MOTORIST COERAGE I undrstand tat if I rjct uninsurd motorist covrag, and if I am injurd by a prson driving witout motor vicl insuranc, I may b unabl to rcovr any significant amount of mony to covr t costs of my injuris or of damag to my motor vicl. I av applid tis day for covrag undr an automobil liability insuranc policy, and t company providing suc covrag and I av agrd as follows to dlt uninsurd motorist covrag from tat insuranc policy: 1. I lct to dlt compltly uninsurd motorist covrag for all insurds. 2. I lct to rtain uninsurd motorist covrag at rducd limits of $15,000 pr prson or $30,000 pr accidnt. 3. I lct to rtain uninsurd motorist covrag at rducd limits of $25,000 pr prson or $50,000 pr accidnt. T following lctions apply to applicants wising to insur at last on privat passngr vicl tat is subjct to commrcial assignmnt: 4. I lct to dlt uninsurd motorist covrag for proprty damag covrag but rtain uninsurd motorist covrag for bodily injury. 5. I lct to dlt uninsurd motorist covrag for proprty damag but rtain uninsurd motorist covrag for bodily injury at rducd limits of $15,000 pr prson or $30,000 pr accidnt. 6. I lct to dlt uninsurd motorist covrag for proprty damag but rtain uninsurd motorist covrag for bodily injury at rducd limits of $25,000 pr prson or $50,000 pr accidnt. Applicant s Signatur X Dat Hour A.M PM T rjction of insuranc indicatd by t abov agrmnt sall b binding upon vry insurd to wom suc policy or ndorsmnt provisions apply wil suc policy is in forc, and it sall continu to b so binding wit rspct to any continuation, rnwal or rplacmnt of suc policy by t namd insurd, or wit rspct to rinstatmnt of suc policy witin 30 days of any laps trof. DO NOT SIGN THIS AGREEMENT UNLESS YOU READ AND UNDERSTAND IT. SECTION 10.c. EMPLOYER S NON-OWNERSHIP LIABILITY Cck r if dsird. Primary Excss Ar any otr vicls ownd by t Applicant? Ar any vicls auling xclusivly for on firm/carrir? If "Ys" complt t following. If "Ys", complt t following. Nam of Insuranc Company Policy # Nam of Firm/Carrir Addrss of Insuranc Company Typ of Businss Dscription of any ownd, lasd, ird, and non-ownd vicls, wic ar not to b insurd. Yar Trad Mak Body Typ icl Idntification # Total # Employs T numbr of mploys tat us tir own (unspcifid) vicls in t applicant s businss? Numbr of Full-tim Equivalnt Drivrs: ( Full-tim quivalnt is dtrmind by dividing t avrag total wkly dlivry-ours for mploys by 40.) Attac crtificats of insuranc from a California-admittd company for ac dlivry-drivr. AIP 1251 CA COMMERCIAL APPLICATION Pag 4 (Rv 09/06)
SECTION 10.d. HIRED CAR COERAGE Cck r if dsird. Cost of Hir sction (10..) must b compltd. Estimatd Annual Cost of Hir Rats Pr $100 Estimatd Prmium B.I. P.D. B.I. P.D. Primary Excss You MUST attac a copy of t truckrs writtn agrmnt wit tir ird carrirs tat complis wit t rquirmnts outlind in Rul 75 in ordr to rciv EXCESS covrag. 1. Dos ac ird carrir av tir own covrag? 2. Ar tr Crtificats of Insuranc or Additional Insurd Endorsmnts on fil wit t insurd? 3. Is tr any intrstat travl? SECTION 10.. COST OF HIRE Indicat t total Cost of Hir, including cost and wags, for vicls lasd or ird on a long-trm basis (ovr 6 monts) and spcifically insurd by applicant as an ownd automobil. Indicat t total Cost of Hir, including cost and wags, for automobils, wic ar not spcifically insurd by t applicant as an ownd vicl but ar to b insurd as ird automobils. (For policis ratd undr Truckr's Cost of Hir.) All risks for wic a broad form filing or MCS-90 ndorsmnt as bn issud Currnt Yar 1st Prior Yar 2nd Prior Yar 3rd Prior Yar $ $ $ $ $ $ $ $ $ $ Cost of Hir Rprsnts Total Long and Sort Trm Cost of Hir. $ $ $ $ $ SECTION 11. GROSS RECEIPTS (Rquird for Motor Carrirs of Proprty or Passngrs wtr or not t policy is to b writtn on Gross Rcipts basis.) 4t Prior Yar Gross Rcipts Currnt Yar 1st Prior Yar 2nd Prior Yar 3rd Prior Yar 4t Prior Yar Otr tan Truckrs $ $ $ $ $ Truckrs xcluding rcipts from trip lasd quipmnt $ $ $ $ $ SECTION 12. PUBLIC AUTOS List all citis troug and in wic vicls oprat: Wr is vicl prmittd to oprat? SECTION 13. FILINGS OR CERTIFICATES How is vicl licnsd? NOTE: All ownd and opratd vicls must b dscribd in tis application. All risks for wic a filing as bn mad (xcpt SR-22) ar subjct to cost of ir rating and mployr s non-ownrsip covrags. If a filing is rqustd r, t Cost of Hir and Employr s Non-Ownrsip Liability sctions must b compltd. Applicant s nam must b idntical to nam as it appars on ICC or Dpt. of Public Safty (DPS) prmit to avoid rjction. Is filing or spcific limit(s) of liability ndd? If "Ys" to comply wit: Motor Carrir Act of 1980 Typ: 1 2 3 4 Bus Rgulatory Act of 1982 ICC Rgulation - Dockt # Local Ordinanc (attac copy) Stat Rgulation U. S. DOT # DM MCP # PUC # Otr If block(s) ar cckd, list stat(s) and city(is) rquiring filings or limits of liability rquird by law. Is applicant rquird to fil vidnc of financial rsponsibility (SR-22)? If "Ys", complt t following. Last Nam First Nam MI Licns # Typ of Filing Ownr s (opration of ownd vicls) Oprators (opration of non-ownd vicls) Bot Stat wr Filing rquird Cas or fil # Rason for Filing Nam of any party rquiring a Crtificat of Insuranc or Additional Insurd Endorsmnt. Wn an Additional Applicant ndorsmnt is rqustd, attac a copy of t agrmnt btwn t applicant and t additional intrstd party. AIP 1251 CA COMMERCIAL APPLICATION Pag 5 (Rv 09/06)
SECTION 14. PAYMENT PLANS GROSS DEPOSIT PREMIUM MUST BE SUBMITTED WITH APPLICATION. 25% of total stimatd prmium or minimum dposit pr vicl, wicvr is gratr, is rquird as a DEPOSIT. Option 1 - Full Annual Prmium Option 2 - Prmium Dposit wit Singl Bill Balanc Option 3 - Installmnt Prmium Paymnts - Dposit plus 5 montly paymnts No intrst carg - $4.00 pr installmnt carg* Option 4 - Installmnt Prmium Paymnts - Dposit plus 9 montly paymnts No intrst carg - $4.00 pr installmnt carg* Prmium to b Financd Nam of Prmium Financ Company** Cck/Mony Ordr/Draft #: Total Estimatd Prmium: $ Amount Submittd wit Application: $ * Not Availabl on Prmium Financd Policis. ** Attac a copy of Prmium Financ contract. NOTICE TO PREMIUM FINANCE COMPANY Unarnd Prmium is basd on actual prmium, not stimatd prmium. SECTION 15. PREIOUS AUTOMOBILE INSURANCE CARRIER Information for t past tr yars. (If a flt, information for t past fiv yars is rquird.) Attac loss statmnts from and basic prmiums paid by prvious carrir. Indicat if risk is a nw vntur. Nam of latst carrir Policy # Trmination dat Was covrag troug Plan? If Ys, giv rason trminatd. Complt t following for Carrirs of proprty and passngrs. 1st Prior 2nd Prior 3rd Prior 4t Prior Policy # Policy Priod From To SECTION 16. EIDENCE OF INSURANCE AND REQUESTED EFFECTIE DATE OF COERAGE Nam of Insuranc Company T Applicant rby autorizs any insurr tat may prviously av providd covrag to t Applicant or to additional namd insurds to provid rcords, data or information concrning prior covrag to t Plan or any carrir dsignatd by t Plan. T Applicant agrs tat a rproduction of tis autorization sall b considrd as ffctiv and valid as t original. 1. T application must b fully compltd and duly xcutd. 2. Covrag undr tis vidnc of automobil insuranc is to b ffctiv for a priod not to xcd 45 days from t ffctiv dat and tim statd rin. Witin suc 45 day priod covrags undr tis vidnc of automobil insuranc will trminat immdiatly upon: (a) t issuanc of t policy applid for, (b) t issuanc of any policy affording similar insuranc, or (c) t cancllation of t covrags of insuranc affordd rundr in accordanc wit t ruls of t California Automobil Assignd Risk Plan. 3. A prmium carg will b mad for ts covrags if t policy, wn and as issud, is not accptd by t insurd. 4. T insuranc affordd rundr sall b subjct to all t trms and conditions of t Plan and t Policy Form prscribd for us. 5. T Producr of Rcord must forward tis application to t Plan Offic witin two (2) working days aftr t application is writtn. NOTE: In t vnt tr is no U.S. postmark (a mtrd mail postmark, lctronic stamp, or otr postag srvic or stamp ar not considrd a U.S. postmark), covrag will bcom ffctiv no arlir tan 12:01 a.m. on t day following rcipt in t Plan Offic. Rqustd Effctiv Dat and Tim: ELECTRONIC EFFECTIE DATE PROCEDURE (EEDP) REFERENCE #: Exampl: 09/ 01/2002 11:30 AM (Only rquird if using EEDP in liu of EASi submission) IN NO EENT SHALL COERAGE BE EFFECTIE PRIOR TO THE DATE AND HOUR OF COMPLETION OF THIS APPLICATION. SECTION 17. PRODUCER OF RECORD STATEMENT I rby crtify tat I am a licnsd brokr/agnt of t Stat of California. I av rad t California Automobil Assignd Risk Plan and av xplaind t provisions to t applicant. I acknowldg tat I am acting on balf of t applicant in submitting tis application and av no autority to stablis or rvis t trms or conditions of covrag. Tis application includs all rquird information givn to m by t applicant. In t vnt of cancllation or a cang to t policy rsulting in a rduction of prmium, I agr to rturn t unarnd prmium to t insurd (nt of any minimum prmium du t carrir) and also to rturn to t carrir unarnd compnsation for tis insuranc rcivd by m as rquird by t Plan. I av xplaind t trms of tis covrag applid for to t applicant and to any financ company utilizd. I crtify, undr pnalty of prjury, tat I av prsonally askd t applicant vry qustion on tis application and accuratly notd ac of t applicant s rsponss. In addition, I crtify tat lgibl potocopis of t applicant s and principal oprator s drivr licns(s) (unlss suspndd or rvokd), as wll as ac vicl rgistration, ar attacd. I crtify tat tis application is submittd pursuant to t ffctiv dat provisions of t California Plan. In t vnt t policy is canclld or a cang is mad rsulting in a rturn prmium to t insurd, I agr to rturn t unarnd commission portion of suc prmium. T information containd rin is accurat to t bst of my knowldg. Dat: Hour: AM Producr s Signatur PM AIP 1251 CA COMMERCIAL APPLICATION Pag 6 (Rv 09/06)
SECTION 18. NOTE FEES ARE ILLEGAL Sction 11624.5 of t California Insuranc Cod provids: No insuranc agnt, brokr or solicitor sall mak any carg to t applicant, dirctly or indirctly, for furnising any prson t ncssary application forms, tcnical assistanc and srvics ncssary to prfct an application troug t Plan otr tan suc commission as is paid by t insurr pursuant to t provisions of suc Plan. SECTION 19. ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR EHICLE INSURANCE COERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THE APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CRIMINAL PENALTIES. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. SECTION 20. APPLICANT S STATEMENT I rby crtify undr pnalty of prjury tat I, 1. av bn informd of my rigt to coos t CAARP intrst-fr Paymnt Plan options as sown in Sction 14 of tis application CHECK ONE: If No plas ask t producr for an xplanation. 2. av duly autorizd t undrsignd to xcut tis application on my balf if t Applicant is not a natural prson. 3. as trid witout succss to obtain automobil insuranc in tis stat witin t prcding 60 days, and tat t Applicant as bn unabl to obtain suc insuranc troug ordinary mtods. 4. to t bst of my knowldg and blif all statmnts containd in tis application ar tru and all ts statmnts ar offrd as an inducmnt to issu t policy for wic I am applying. 5. raliz tat any mislading information or failur to disclos rquird information will b considrd lack of good fait on my part and may void t application or caus cancllation of my covrag. 6. agr tat no covrag will b in ffct if my prmium rmittanc, wic accompanis tis application, is justifiably disonord by any financial institution. 7. undrstand tat t prmium sown on tis application is an stimatd prmium. T carrir rsrvs t rigt to adjust t prmium itr prior to or aftr t issuanc of t policy. I agr to pay t adjustd/dvlopd prmium wic may b igr tan t original stimat. 8. will pay all prmiums wn du. 9. dsignat as Producr of Rcord of tis insuranc t Producr or firm namd in tis application. A substitut Producr may b dsignatd by m at any tim and, upon dsignation sall b t Producr of Rcord. I undrstand tat any dsignatd Producr cannot act as an agnt of t California Automobil Assignd Risk Plan or any carrir for t purpos of tis insuranc and tat t Producr as no autority to stablis, altr or amnd trms or conditions of covrag. 10. do not ow any insuranc company for automobil insuranc prmiums du or contractd during t prcding 36 monts. 11. undrstand tat if I ow mony for a prior CAARP policy wic I av not formally appald to t California Insuranc Commissionr, t mony I submit wit tis application for a nw CAARP policy will b applid to tat prior policy, and I am not ntitld to a rfund of t mony I av submittd wit tis application, vn if covrag for tis nw policy is trminatd, until I pay t full amount owd for all currnt and prior CAARP policis. 12. undrstand tat t agnt/brokr is not acting as an agnt of any company for t purposs of tis insuranc. 13. will rmit a cck, mony ordr or a bank draft of min, producr of rcord or financial institution, as dirctd by t insurr, for t balanc of t full prmium for t policy, witin 30 days of notification or, if I av lctd a Paymnt Option in Sction 14 of tis application, to mak paymnts as spcifid in t CAARP Intrst-fr Paymnt Plan Rgulation (Sction 44). 14. tat tis application was writtn and signd as of t dat sown. 15. tat wn t insuranc is to b writtn on a basis rquiring final adjustmnt of t prmium aftr xpiration of t policy, I will maintain a complt rcord of all financial transactions in any rasonabl form and mannr as t insurr may rquir. I will also mak tis rcord availabl for inspction by t insurr at a dsignatd plac and at all rasonabl tims. I rby autoriz any insurr tat may prviously av providd covrag to m or to additional namd insurds to provid rcords, data or information concrning prior covrag to t Plan or any carrir dsignatd by t Plan. I agr tat a rproduction of tis autorization sall b considrd as ffctiv and valid as t original. Dat: Hour: AM PM Namd Applicant's or Corporat Officr's Signatur NOTICE TO APPLICANT AND PRODUCER In t vnt acknowldgmnt of covrag is not rcivd witin 30 days, notify t Plan Offic at PO Box 7917, San Francisco, CA 94120 FAIR CREDIT REPORTING ACT NOTICE In addition to routin vrification of information prtinnt to t insuranc applid for, if t application is by an individual for insuranc primarily for prsonal or family purposs, t insurr to wic it is assignd may av an invstigativ consumr rport mad including information baring on caractr, gnral rputation, prsonal caractristics or mod of living and, upon t individual s writtn rqust, will disclos in writing t natur and scop of t invstigation rqustd, if suc rport is procurd. REMARKS SECTION AIP 1251 CA COMMERCIAL APPLICATION Pag 7 (Rv 09/06)