Auto Insurance by AustinNwabueze

VIEWS: 29 PAGES: 20

									                                                                                                                                                                                                                                                        DATE      08/18/11
         ACORD                 TII     TEXAS PERSONAL AUTO APPLICATION
i PRODUCER                                                                                                          APPLICANT'S            NAME AND MAILING ADDRESS (Include county & ZIP+4)


\VGW INSURANCE   LLP                                                                                                FREDERIO    MAUREL                                                                                                     MAlC CODE                      FACILITY CODE

'PO BOX 969                                                                                                         LAURENCE    BETTENFELD
IVAN ALSTYNE,   TX 75495                                                                                            7500 BENELUX    CT                                                                                                     TELEPHONE NUMBER

ipH: 972-727-8949                                                                                                   PLANO    TX 75025                                                                                                      214-263-2286
                                                                                                                    cO~~Trinity                            Universal                            ~po~~~,~                                                                                        ~


             050-01435                                                                                             Insurance €ompany
 CODE:
, AGENCY CUSTOMER ID
                                                      SUBCODE:
                                                                                                                      EFFECTIVE DATE/                  EXPIRATION DATE                                                                                                           IFIRE.DIST

l
 -RE-SIDENC-E---'-CU-RR-EN-T~IDENCE
        Ii
rvri<iIYRS ADDRrpfiEvious
 CURR PREii'I'"
                                                                   IS
                                     ADDRESS (If les. than 3 ye ••.• )
                                                                                               __
                                                                        ~:.::W-:.:.:N-=E-D=--..J. L.RENTED
                                                                                     .
                                                                                                                    08/23/11
                                                                                                                                   _'_"1             08/23/12
                                                                                                                                                               GARAGE
                                                                                                                                                               ~HI
                                                                                                                                                                "
                                                                                                                                                                                            LOCATION              IF DlFF        FROM      ABOVE        (Inc     county        &~-



i 3+                 i                                                                                                                                               I
                                                                                                                                                              TOTAL NUMBER OF VEHICLES IN HOUSEHOLD'
    VEHICLE         DESCRIPTION/USE

VEt<      .YEAR                                            MAKE, MODEL AND BODY TYPE                                                            j                                            VlNlREGISTERED STATE
                                                                                                                                                                                                                                                               DATE             ••
                                                                                                                                                                                                                                                                           .P.~'W ,N~J
 1 07                     MITS          OUTLANDER                        ES/LS                      4W                                          I         ITA4MS31X27Z011719                                                                                                              \A
 2 11                     HOND          PILOT EX                        4W                                                                                5FNYF3H47BB010846                                                                                                               ~


\IE>!     COST NEW

    1 21370
                             ~~\!,~~ TERR
                              013 266
                                                     MILE 1 WAY
                                                      WKISCItL

                                                      5
                                                                  • DAYS
                                                                   WEEK

                                                                    5
                                                                              .-.
                                                                             MONTH

                                                                              4
                                                                                           USAGE


                                                                                            C
                                                                                                        ..,..
                                                                                                        FORM
                                                                                                                   MULn·
                                                                                                                    CAR


                                                                                                                    N
                                                                                                                             CAR
                                                                                                                            I'OOL

                                                                                                                             N
                                                                                                                                        GAR·
                                                                                                                                        AGED    IO£9~

                                                                                                                                                W/noe
                                                                                                                                                                              ~~\1~~ DRIVEIt DRIVE j{USE (Each
                                                                                                                                                                             10000 2
                                                                                                                                                                                                    GOVERN




                                                                                                                                                                                                     51 48
                                                                                                                                                                                                                                            veh mu     t equal 100%)
                                                                                                                                                                                                                                                                                 CLASS
                                                                                                                                                                                                                                                                          5402200lC
    2 30895                  23     266               5             5         4             C                       N        N                      q (}()n                  12000 1         51                                                                           4169200lC

                                                                                                                                               T
 va< IS~~~~T             In~~:~¥..
                                         AN11ol.0CK
                                         BRAKES 214        ANTI·THEFT DEVICES                      CREDITS AND SURCHARGESI                          ....   s~!~SIVE
                                                                                                                                                                 BELT ID~~~¥..
                                                                                                                                                                                                      AHTI-UlCK
                                                                                                                                                                                                      BJW(ES2J4          ANTI·THEFT DEVICES            CREDITS AND SURCHARGES

    1         8                             Y              P
    2         8                             Y              P
    COVERAGES/PREMIUMS                                                                                                                                                                                                                                                                  .-
                    COVERAGES                                                                              LIMITS OF LIABILITY                                                                        VEHICLE'               VEHICLE"              VEHICLE"                VEHICLE.

    SINGLE LIMIT lIABILITY (CSl)                       $                                           EAACCIDENT                                                                                         s                      $                     s                      $
    BODilY    INJURY LIABilITY                         $50000                                      EAPERSON                   $100000                                    EAACCIDENT                   $308.00 $108.00 $                                                   $
    PROPERTY DAMAGE LIABILITY                          $50000                                      EAACCIDENT                                                                                         $406.00 $138.00 ~                                                   $
    PERSONAl.. INJURY                                  $                                           EAPERSON
    PROTECTION                                         $                                           AUTO DEATH
                                                                                                                              $                                      ~?:TA,*,I ITV
                                                                                                                                                                                                      $                      s                     $                      $

    MEDICAL PAYMENTS                                   $                                           EAPERSON                                                                                           $                      $                     $                      $
                                              CSL      $                                           EAACCIDENT
    UNINSUREDI                                                                                                                                                                                        $56.00                 $56.00                $                      $
    UNDERINSURED                                BI    $50000                                       EAPERSON                   $100000                                    EAACCIDENT
    MOTORISTS
                                                PO    $50000                                       EAACCIDENT                 $ 250                                      DEDUCllBlE                   $40.00   $40.00                              $                      $
    COMPREHENSIVE                            OED      1 $500                             ~ $500                                $                                 $                                    $64.00   $44.00                              $                      $
    OTHER THAN COLLISION                     OED           $                                $                                  $                                 $                                    $        $                                   $                      $
    COlliSION                                OED      1 $500                             12 $500                               $                                 $                                    /$620.00 $284.00                             $                      s
    ACV UNLESS AMOUNT STATED                            $           $                                                               s                            $                                    $                      $                     $                      1$
    TOWING      &   LABOR                             1 $75      2 $75                                                              $                            s                                    $8.00    $8.00   $                                                  s
    TRANS EXPIRENT AI..RE                             1 $30 /dav 12 $30 /dav                                                        $           /                $                 /                  $12.00   $12.00  s                                                  Is

                                                                                                                                                                                                      $        ~                                                          $
i   ADDITIONAl.. COVERAGESIENDORSEMENTS                        (Include limit, deductible, premium)                       I POLICY FEE: $                                I    ITgJ~,!,'~R             $1514.00 $690.00                                                    $
IAU997!O                                                                                                                                                                                                  ESTIMATED TOTAL         11         DEPOSIT                      BAlANCE DUE

L.                                                                                                                                                                                                    $      2206.00                   $                          Is      2206.00
    RESIDENT             &   DRIVER      INFORMATION                (List      all       residents             &   dellendents                 licensed       or not)             and       reaular         ooeratorsl

    1#
    1 FREDERIC
              NAME (AS IT APPEARS ON LICENSE)

                 MAUREL
                                                                   SEX

                                                                    M M
                                                                            lIAR
                                                                            STAT
                                                                                     REI- TO
                                                                                     APPtJC          ~~~
                                                                                                   03/19/68
                                                                                                                              OCC

                                                                                                                           ACCO
                                                                                                                                                DATE LIC "roo
                                                                                                                                               03 84 N N N
                                                                                                                                                              ~              '=-                ~~~m~
                                                                                                                                                                                              Def     Drv:N
                                                                                                                                                                                                                         DRIVERS LICENSE fILIC STATE

                                                                                                                                                                                                                    28514434                     TX
                                                                                                                                                                                                                                                                    SOCIAL SECURITY.

                                                                                                                                                                                                                                                                  IxxxXX8902
    2 L.BETTENFELD                                                  F M                            08/21/68                ACCO                08 84 N N N                                    Det Drv:N             27846926                     TX
    3 ANAIS MAUREL                                                  F S                            04/02/95                STUD                04 11 N Y N                                    Def Drv:N             33552414                     TX

    ACCIDENTS/CONVICTIONS         eNote:  Your                              drlvlna            record           Is verified             wit h the     state    motor              vehicle         denartment)
    HAS ANY DRIVER SHOWN ABOVE HAD AN ACCIDENT                                                                                                                                                                            IF YES, INDICATE BELOW. ALSO INCLUDE
                                                                                                                                   ,.ft.            .'5     ""ADQ?            I         I    YEslxl            NO
    D~V                  DATE OF
                                                                                          DESCRIPTION OF ACCIDENT OR                            ONVICTlON                                                                        PLACE O~"TlIW
                                                                                                                                                                                                                                                        I ~~':   ~";';         AMOUNT OF
                                                                                                                                                                                                                                                                           PROPI!RTY   DAMAGe




I
L.                                    --                                                                                                                                                                                                                                                   --
    ACORD           90    TX     (2001103)                                                                     PLEASE          COMPLETE                   REVERSE             SIDE                                                     © ACORD          CORPORATION                    1981
_ADDITIONAL
  ..                        INTEREST                                     ._--_. ----.---_.                                            -                                                                                        --

                                                                                                                       I
    VEH#                         NAME AND ADDRESS                                                                                                                                            LOAN NUMBER
              f--      ADDLINT
                       LOSS PAY
    VEH#                             NAME AND ADDRESS                                                                                                                                        LOAN NUMBER
              f-- ADDLINT                                                                                              I
                       LOSS PAY
    EMPLOYMENT      INFORMATION                             (* If less    than    2 vears. orovlde  name of D~vious              emDlover       and   Drevlous     cccueatlon   under Remarks)


                                                                                                                       I
                                                                                    ADDRESS OF EMPLOYMENT                                                                   WORK PHONENUMBeR                YEA-RSWI           WI
    APPLICANrs EMPLOYER                                                                                                                                                                                     URREllPL
                                                                                                                                                                                                                         YEARS
                                                                                                                                                                                                                         PREYEUPl
    (State   natura   of business   if   self .• mployed)


    CO-APPUCANrs EMPLOYER

                                                                                                                       I
                                                                                    ADDReSS OF EMPLOYMENT                                                                   WORK PHONE NUMBeR               YEARS WI
                                                                                                                                                                                                            URRfMI'l,:
                                                                                                                                                                                                                          YEARS   WI
    IStat. nature of bUllnes,1I ,.I!-employed)                                                                                                                                                                            PREVEMPL




    PRIOR COVERAGE
    PRIORCARRIERAND PRODUCER

    ENCOMPASS
    GENERAL             INFORMATION
    EXPLAIN ALL "YES· RESPONSESIN REMARKS                                                                  YES NO EXPLAINALL "YES· RESPONSESIN REMARKS                                                                   YES NO

    1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES                                                            9. ANY HOUSEHOLD MEMBER IN MIUTARY SERVICE? (Driver number)                                            X
       NOT SOLELYOWNED BY AND REGISTEREDTO THE APPUCANT?                                                       1           10.ANY DRIVERSLICENSE BEEN SUSPENDEOIREVOKED?                                                          X
    2. ANY CAR MODIFIEDISPECIAL EQUIPMENT? (Include customized vans/pickups; indicate co I)                    X           11.ANY DRIVER HAVE PHYSICAUMENTAL IMPAIRMENT? (Lisl driver numbers)                                    X
    3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass)                                                 X           12. ANY   FINANCIAL RESPONSIBILITY FILING? (Driver number and dale of filing)                          X
    4. ANY OTHER LOSSES INCURRED (not shown in Accident/Conviction area)?                                      X           13. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY?                                             V
    5. ANY CAR KEPT AT SCHOOL?                                                                                 X           14.ANY COVERAGE DECLINED, CANCELLED, OR NON·RENEWED DURINGTHE
                                                                                                                              LAST 3 YEARS?                                                                                       X
    6.   ANY CAR PARKEDON STREET?                                                                              X
    7. ANY    OTHER AUTO INSURANCE IN HOUSEHOLD? (Include any provided by employer)                            X           IS, IS THIS BROKERED BUSINESS TO THE AGENT?                                                            X
    8. ANY OTHER INSURANCE WITH THIS COMPANY? (List policv number)                                        fx               16.HAS AGENT INSPECTED VEHICLE?                                                                        X
    REMARKS                                                                                                                               ATTACHMENTS
    TX Anti-Theft                                    Prevention                     Fee: 2.00                                                 STATE SUPPLEMENT                           MOTOR VEHICLEREPORT
                                                                                                                                              NO-FAULT APPLICATION                       PHOTOGRAPH
                                                                                                                                              YOUNG DRIVER QUESTIONNAIRE                 BILL OF SALE
                                                                                                                                              DRIVER TRAINING CERTIFICATE
                                                                                                                                              GOOD STUDENT CERTIFICATE
    FOR COMPANY USE ONLY                                                                                           I
                                                                                                                                              ANTI-THEFT DEVICE CERTIFICATE
                                                                                                                   I                          MEDICAL STATEMENT
    BINDER/SIGNATURE
                 INSURANCEBINDER       IF THE ·BINDER" BOX TO THE LEFT IS COMPLETED. THE FOLLOWING CONDITIONS APPLY;
         EFFECnve DATE                 THIS COMPANY BINDS THE KINDg;) OF INSURANCE STIPULATED ON THIS APPLICATION,
                          EXPIRATIONDATE                                                                                 THIS INSURANCE IS SUBJECT
[                                      TO THE TERMS. CONDITIONS AN LIMITATIONS OF THE POLlCY(IES) IN CURRENT USE BY THE COMPANY.
                                       THIS BINDER MAY BE CANCELLED BY TH~ INSURED BY SURRENDER OF THIS BINDER OR BY WRmEN           NOTICE TO THE
I        nME                           COMPANY STATING WHEN CANCELLATION       WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY
                         /12:01 AM
I
,
                                       BY NOTICE TO THE INSURED IN ACCORDANCE     WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHEN
                           NOON            I
                                       REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY. THE COMPANY IS ENTITLiED TO CHARGE A
                                       PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM                                                                                     IS
      / COVERAGE 15NOT BOUND           SUBJECT TO VERIFICATION    AND ADJUSTMENT    WHEN NECESSARY     BY THE COMPANY.
  NOTICE OF INSURANce INFORMATIONPRACTICeS                                                                     ~
  PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU. SUCH INFORMATION                  AS WELL AS OTHER PERSONAL
  AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES              BE DISCLOSED TO THIRD PARTIES. YOU HAVE
  THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION         IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES.       A MORE DETAILED
  DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INF6~MATION             IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR
  BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
    ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION                              FOR INSURANCE
    CONTAINING ANY MATERIALLY FALSE INFORMATION          OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION                CONCERNING    ANY FACT MATERIAL
    THERETO COMMITS A FRAUDULENT          INSURANCE ACT WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
    APPLICANrS STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO
    THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE CqMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING. IN ADDITION,IF
    THE AUTO PLAN OR COMPANY DESIGNATED IN THIS APPLICATION IS NON-STANDARD, t CERTIFY THAT I UNDERSTAND THE RATES FOR THIS COVERAGE ARE HIGHER THAN NORMAL. AND THAT
    THEY ARE ACCEPTABLETO ME AS I HAVE BEEN UNAB4E TO OBTAIN COVERAGE DESIRED THROUGH THE NORMAL INSURANCE MARKET.
                                                                                                               I

    PRODUCER'S             STATEMENT:              I CERTIFY    TO THE BEST OF MY KNOWLEDGE              AND BELIEF THAT THE SIGNATURE                       OF THE
                      APPLICANT          IS THE PERSONAL           SIGNATURE         OF THE APPLICANT.                                                                          I   HOW~~~
                                                                                                                                                                                    KNO
                                                                                                                                                                                                HAVE YOU
                                                                                                                                                                                               E APPLICANT?
    I UNDERSTAND AND ACKNOWLEDGE       THAT UNINSURED/UNDERINSURED     MOTORISTS (UMlUIM). BODILY INJURY (BI) AND PROPERTY DAMAGE (PO)
    COVERAGES HAVE BEEN EXPLAINED TO ME. I HAVE BEEN OFFERED THE OPTIONS OF SELECTING UMlUIM LIMITS EQUAL TO MY LIABILITY LIMITS.
    UM/UIM LIMITS LOWER THAN MY LIABILITY LIMITS OR TO REJECT UM/UIM BI AND/OR UM/UIM PO COVERAGES         ENTIRELY.
    1. I SELECT UNINSUREDIUNDERINSURED     MOTORISTS BODILY INJURY LlMIT(S) INDICATED IN THIS APPLICATION.                         (INITIALS)
    2. I REJECT UNINSUREDIUNDERINSURED                               MOTORISTS         BODILY INJURY AND PROPERTY              DAMAGE        COVERAGE        IN ITS ENTIRETY.                           (INITIALS)
    3. I REJECT ONLY UNINSUREDIUNDERINSURED                                      MOTORISTS   PROPERTY    DAMAGE COVERAGE                  IN ITS ENTIRETY.                                              (INITIALS)
    I UNDERSTAND AND ACKNOWLEDGE    THAT PERSONAL INJURY PROTECTION C0VERAGE HAS BEEN EXPLAINED TO ME
    AND I HAVE BEEN OFFERED THIS COVERAGE. IF I HAVE REJECTED THIS COVERAGE, MY INITIALS ARE INCLUDED HERE.                                                                                          (INITIALS)

    I UNDERSTAND THAT THE COVERAGE                                SELECTION AND LIMIT CHOICES INDICAIED HERE OR IN ANY STATE, SUPPLEMENT                                   WILL APPLY TO ALL FUTURE
    POLICY RENEWALS. CONTINUATIONS                               J ~ CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.




                                                            -V t                                    G()~I~II I                                         I
    ==t)(~~~                                                                                             ,
                                                                                                                                          PRODUCER'S
                                                                                                                                          SIGNATURIE

    ACORD90'lX'(2                               3)
USE OF CREDIT INFORMATION                    DISCLOSURE
Insurer's Name            Trinity Universal Insurante Company
Address     Customer Relations. PO. Box 3327, Fcranton, PA 18505


Telephone Number (toll free if available) _---.l8l.J7uj!=.-2L:5;L2'=-:L7o.87LJ8~------.----

We will obtain and use credit information on you or any other member(s) of your household as a part of
the insurance credit scoring process.

If you have questions regarding this disclosure, contact the insurer at the above address or phone
number. For information or other questions, contact the Texas Department of Insurance at
1-800-252-3439 or P.O Box 149091, Austin, Te as 78714.

Article 21.49-2U, Sec. 7{d), of the Texas Insura ce Code requires an insurer or its agents to disclose to
its customers whether credit information will be obtained on the applicant or insured or on any other
member(s} of the applicant's or insured's household and used as part of the insurance credit scoring
process.                                           I
If credit information is obtained or used on the applicant or insured, or on any   member of the applicant's
or insured's household, the insurer shall disclose to the applicant the name       of each person on whom
credit information was obtained or used and how each person's credit               information was used to

                                                   I
underwrite or rate the policy. An insurer may provide this information with this
notice.
                                                                                    disclosure or in a separate


Adverse effect means an action taken by an insurer in connection with the underwriting of insurance for
a consumer that results in the denial of coverage, the cancellation or nonrenewal of coverage, or the offer
to and acceptance by a consumer of a policy form, premium rate, or deductible other than the policy
form, premium rate, or deductible for which the consumer specifically applied. Credit information is any
credit related information derived from a credit report itself, o( provided in an application for personal
insurance. The term does not include information that is not credit-related, regardless of whether the
information is contained in a a credit report or in an application for insurance coverage or is used to
compute a credit score.

Credit score or insurance score is a number or rating derived from a mathematical formula, computer
application, model, or other process that is based on credit information and used to predict the future
insurance loss exposure of a consumer.


 SUMMARY OF CONSUMER PROTECTIONS CONTAINED IN ARTICLE 21.49-2U

 PROHIBITED USE OF CREDIT INFORMATION.                 n insurer may not:
 (1) use a credit score that is computed using fartors that constitute unfair discrimination;

 (2) deny, cancel, or nonrenew a policy of personal insurance solely on the basis of credit information without
 consideration of any other applicable underwriting factor independent of credit information; or

 (3) take an action that results in an adverse effect against a consumer because the consumer does not have
 a credit card account without consideration of any other applicable factor independent of credit information.




 CD-1 (ED. 11/03)                                                                                  Page 1 of2
                                        ·_ ..   -----

                                                        .'       ation or an inability to determine. credit
An insurer may not consider ~n absence of c d~r I~~:d               as a factor in underwriting or rating an
information for an applican~ for I~surance coverage
insurance policy unless the Insurer.
                                                        I .. information that: (A) is reasonably related ~o
 (1) has statistical, actuarial, 0: rea~onable )unhderwr~~~rhe absence of credit information could result In
                                                           t
 actual or anticipated loss experience, and (8 s a s
 actual or anticipated loss differences;
                                   .         .      tor :              erage or insured had neutral credit
  (2) treats the consumer as .If the. applicant or Insurance cov
  information, as defined by the Insurer, or
 (3) excludes the use of credit information as a actor in underwriting and uses only other underwriting
 criteria.

  NEGATIVE FACTORS. An insurer may not use any of the following ~s a negative fact?r in any credit
  scoring methodology or i~ revie~ing <?r?~it information to un?erwnte or rate a policy of personal
  insurance: (1) a credit inquiry that IS not initiated by the consumer,

  (2) an inquiry relating to insurance coverage, if so identified on a consumer's credit report; or

  (3) a collection account with a medical industry       ode, if so identified on the consumer's credit report.

  Multiple lender inquiries made within 30 days of a prior inquiry, if coded by the. consu~er ~eporting
  agency on the consumer's credit report as from the home mortgage or motor vehicle lendmg industry,
  shall be considered by an insurer as only one inquiry.

  EFFECT OF EXTRAORDINARY EVENTS. An insurer shall, on written request from an applicant for
  insurance coverage or an insured, provide reasonable exceptions to the insurer's rates, rating
  classifications. or underwriting rules for a consumer whose credit information has been directly influenced
  by a catastrophic illness or injury, by the death of a spouse, child, or parent, by temporary loss of
  employment, by divorce, or by identity theft. In such a case, the insurer may consider only credit
  information not affected by the event or shall assign a neutral credit score.

  An insurer may require reasonable written andlindependentlY verifiable documentation of the event and
  the effect of the event on the person's credit before granting an exception. An insurer is not required to
  consider repeated events or events the insurer reconsidered previously as an extraordinary event.

  An insurer may also consider granting an exception to an applicant for insurance coverage or an insured
  for an extraordinary event not listed in this section. An insurer is not out of compliance with any law or
  rule relating to underwriting, rating, or rate filing/ as a result of granting an exception under this article.

  NOTICE OF ACTION RESULTING IN ADVERSE EFFECT. If an insurer takes an action resulting in an
  adverse effect with respect to an applicant for insurance coverage or insured based in whole or in part on
  information contained in a credit report, the insurer must provide to the applicant or insured within 30

                                                     I
  days certain information regarding how an applicant or insured may verify and dispute information
  contained in a credit report.

  DISPUTE RESOLUTION; ERROR CORRECTION. If it is determined through the dispute resolution process
  established under Section 611(a)(5), Fair Credit Reporting Act (15 U.S.C. Section 1681i), as amended,
  that the credit information of a current insured was inaccurate or incomplete or could not be verified and
  the insurer receives notice of that determinatiorn from the consumer reporting agency or from the insured,
  the insurer shall re-underwrite and re-rate the i sured not later than the 30th day after the date of receipt
  of the notice.

  After re-underwriting or re-rating the insured, the insurer shall make any adjustments necessary within 30
  days, consistent with the insurer's underwriting and rating guidelines. If an insurer determines that the
  insured has overpaid premium, the insurer shall credit the amount of overpayment. The insurer shall
  c0":1pute the overpayment back to the shorter of the last 12 months of coverage; or the actual policy
  period.




  CD-1 (ED. 11/03)                                                                                      Page 20f2
PERSONAL INJURY   The law in Texas requires hat your policy provide Personal Injury Protection
PROTECTION        Coverage whenever bodily injury coverage is written. This coverage provides
COVERAGE          benefits for medical and funeral expenses, loss of income from employment and
                  reasonable expenses incurr d for obtaining services, as the result of a motor
                  vehicle accident sustained by you. Read your policy carefully for specific
                  details and exclusions. If you have any questions, your agent will be glad to
                  answer them.


REJECTION FORM    If you do not want Personal Injury Protection Coverage you must reject the
                  coverage in writing.    To do so, check the box and sign your name below.
                  Please return this form to your agent.


                  ~                                               ~
                         I hereby reject Personal Injury Protection

                  Signature of Named Insured®         ~~                                      _



                  Date                          Policy Number                             _




 AK 1605 (0590)
                                                     ..   ~




Kem.per
IMPORTANT NOTICE REGARDING OUR PRIVA9Y POLICY                                .
The Companies listed below have policies and practices that respect the pnvacy          .of our customers and
consumers. If you have Personal Lines Coverage with u~ or If you have a~                Insurance. transaction
involving such coverage, this ~oti~~ applies ~o you. It pertains to your nonpubhc        personal Information.
We shall refer to it as "Information In this notice.      I.                                . .
We reserve the right to revise this policy at any time. ":Ie Will send you a new         notice If changes are
 made that will result in other disclosures of your In~lormatlon.
Types of Information We May Collect
We may collect Information about you that we receive from:
    You on applications and other forms. Examples include your name, address, date of birth, phone
    number, social security and driver license num/bers;
    Your agent;
    Your transactions with our affiliates, others, or us. Examples include your policy's account balance,
    your premium payment history, and your bank account number; and
    Outside sources such as consumer           reporting agencies,   including   motor vehicle records, credit
    reports and claim history reports.
Types of Information We May Disclose, And To Whom
We may disclose all of the Information above, witm some exceptions, to other companies.
For instance, we may share your          Information with companies that perform marketing for us or with
financial institutions that have joint   marketing ag eements with us. If we do, we may disclose to those
companies all of the information          described above, although we will not disclose your non public
personal health information, without      your permission, for the sole purpose of joint marketing.
We will not share your Information with anyone else without your permission unless:
       1. They are helping us service or process a transaction, or
       2. We are otherwise permitted or required by law to do so.
Examples of others with whom we may share your Information without your permission include:

                                                     I
    People or organizations that perform a business function for us. Examples are a company that
    helps us:
        1. print payment coupons,
       2. adjust or investigate claims,
       3. program software to help us process customers' transactions; or
       4. market our own products or minimize unnecessary marketing to you.
    Your agent or broker;
    Requlatory and law enforcement        authorities, such as government offices or courts which subpoena
    records;
    Insurance support organizations      which gather data to help deter or prevent insurance crimes;
   Other insurance companies      or
                                  support organizations for an insurance transaction involving you. An
   example IS the purchase of reinsurance;
   Businesses which conduct actuarial or resea ch studies' ,
   Our affiliates, for internal or agency audits of the marketing of an insurance product or service; and
   A company that may acquire a line of business or function or book of business from us.



AK S167 (01 10)
                                                                                                  Page 1 of2
Security of Your Information
We have procedures and policies to help us protee your Information from unauthorized use or access.
At our companies, we restrict access to protected information to the employees who have a business
need for it. When we share Information with companies who work on our behalf, we protect it where
required by federal law with a confidentiality agreement. We also have physical, electronic and
procedural safeguards to guard your Information.      I
If You Are an Internet User
If you use the Internet and access the website   at       one or more of our companies,   it may have other
information on your use of that website.
STATE EXCEPTIONS
This notice is not intended for use in Arizona, California, Connecticut, Georgia, Maine, Minnesota,
Montana, Nevada, North Carolina, Ohio, Oregon 011 Virginia. If you have Personal Lines Coverage with
us in one of these states, or are involved in an ins ranee transaction involving such coverage in one of
these states, additional privacy provisions also app y. Contact the company or your agent for a copy of
the privacy policy applicable in your state.


UNITRIN AUTO AND HOME INSURANCE COMPANY, KEMPER INDEPENDENCE    INSURANCE
COMPANY, UNITRIN PREFERRED INSURANCE COMPANY, UNITRIN ADVANTAGE INSURANCE
COMPANY, TRINITY UNIVERSAL INSURANCE COMPANY, VALLEY PROPERTY & CASUALTY
INSURANCE COMPANY, VALLEY INSURANCE COMPANY, UNITRIN SAFEGUARD INSURANCE
COMPANY, UNITRIN COUNTY MUTUAL INSllJRANCE COMPANY, MERASTAR INSURANCE
COMPANY




AK 5167 (0110)                                                                                 Page2of2
     TEXAS UNINSURED            MOTORISTS            COVERAGE            SELECTION/REJECTION


     Policy Number


     Texas law permits you to make certain decisions regarding Uninsured Motorists Coverage. This document
     briefly describes this coverage and the options availa Ie.
     You should read this document carefully and contact us or your agent if you have any questions regarding
     Underinsured Motorists Coverage and your options with respect to this coverage.
     This document includes general descriptions of c0l' erage. However, no coverage is provided by this
     document. You should read your policy and review your Declarations page(s) and/or Schedule(s) for
     complete information on the coverages you are provi ed.
     Please review your policy carefully and if you wisl'l to make any change, complete and sign the form
     and return it to your agent. The options you select will apply to subsequent renewal policies unless
     we receive a written request for change from you at a later date. Coverage changes will become
     effective upon our receipt and approval of your request.

     UNINSURED MOTORISTS                COVERAGE

     Uninsured Motorists Coverage provides insurance wotection to an insured for compensatory damages
     which the insured is legally entitled to recover from the owner or operator of an uninsured motor vehicle
     because of bodily injury or property damage caused b an automobile accident. Also included are damages
     due to bodily injury or property damage that result from an automobile accident with a hit-and-run vehicle
     whose owner or operator cannot be identified.
     Effective Prior to 01-01-2011
     Unless rejected, Uninsured Motorists Coverage will be afforded at limits at least equal to: (1) split limits of
     $25,000 for each person, subject to $50,000 for eac~ accident with respect to bodily injury, and $25,000
     with respect to property damage; or (2) a combined s'ngle limit of $75,000 for each accident, but you may
     select optional higher limits.
     Effective 01-01-2011 and Later
     Unless rejected, Underinsured Motorist Coverage will be afforded at limits at least equal to: (1) split limit of
     $30,000 for each person, subject to $60,000 for eacti accident with respect to bodily injury, and $25,000

                                                                   I
     with respect to property damage; or (2) a combined single limit of $85,000 for each accident, but you may
     select optional higher limits.
     Please indicate your choice from either A. or B. as follows:




                                  Includes copyrighted material of tHe Insurance Services Office.
                                                       with its permisslon,
AK 5654 (09 10)                                    © ISO Propertie~, Inc., 2007                             Page 1 of2
   A.     Selection Of Uninsured Motorists ~overage L'mits                    do so by initialing next to the appropriate
          If you wish to. se~ectUninsured Motonst~h~~:;~~~Y ~~~;nJ~nsured Motorists Coverage limits up to
          item(s) and sIgning bel?~. Plefase note\. even though higher limits may appear below.
          the Liability Coverage limIts 0 your po ICY,             I                 . . .,             .
           (Initials)
                            I select Uninsured Motorists           overage at the   fo\\owmg "mltls).

                            (Choose one Split Limits Bodily I~ju!y op~ion AND one Pro~ert~ Damage limit
                            option, OR one Combined Sililgle Limit option from the following).


                                                                        Property                                Combined
                            Split Limits                                                                          Single
                            Bodily Injury         (Initials)   AND      Damage       OR    (Initials)
           (Initials)                                                                                             Limit

                                                                       $ *25,000                            $    *75,000
                          $ *25,000/50,000
                                                                          25,000                                  85,000
                             30,000160,000
                             50,000/100,000      ®                        50,000                                  100,000
                                                                                                                  150,000
                            100,000/300,000                              100,000
                            250,000/500,000                            **500,000                                  200,000

                            300,000/300,000                                                                       300,000

                           **500,000/500,000                                                                      325,000
                                                                                                                  400,000
                                                                                                                 **500,000

           * These limits are ONLY available until 01-01-2011
               hese limits are NOT aval ble     new business.




     B.    Rejection Of Uninsured Motorists Coverage
           If you wish to reject Uninsured Motorists Coverage, you may do so by initialing and signing below.

                                                               I
           Any rejection will apply to future renewal policies unless we receive a written request at a later date to
           add.the rejected coverage to your policy.

             (InitialS)      I reject Uninsured Motoris s Bodily Injury and Property Damage Coverage in its
                             entirety.
             (Initials)
                             I reject ~       Uninsured Motorists Property Damage Coverage in its entirety,



            Signature Of Applicant/Named         Insured                                                         Date


            Policy Number




AK 5654 (09 10)                                                                                                         Page 2 of2
                                                                                     --


                                                                                                                                                                                                            DATE
    ACORDm                     CANCELLATION                                            REQUE ~T I POLICY RELEASE                                                                                    8/18/2011
PRODUCER                                 I   Wg,N:o,   Ext):   (972)       727   -8949       I                 I      COMPANY    NAME AND ADDRESS                              NAiCCODE:

VGW/Walker                 Insurance               Agency                                                             ENCOMPASS
P.O.       Box          969


Van       Alstyne                                 TX         75495


CODE:     1119110000                                     I   SUB CODE:                                                POLICY
                                                                                                                      TYPE
~3g~8~ERID:   00059991                                                                                                           Private          Passenqer           Auto
INSURED    NAME AND ADDRESS                                                                                           CANCELLED POLICY INFORMATION
Frederic                 Maurel
Laurence                Bettenfeld                                                                                    ~~~;~R      US281376288
7500        Benelus           ct                                                                                                                               CANCELLATION        DATE           TIME
                                                                                                                              EFFECTIVE DATE AND                                                                        HAM
Plano                                             TX         75025                                                           HOUR OF CANCELLATION              08/23/2011                                                     PM




                    I
        I CANCELLATION            REQUEST (Policy attached)
                                                                                                                  I
                                                                                                     I I POLICY RELEASE (Complete
                                                                                                                                   POLICY TERM
                                                                                                                                                               EFFECTIVE

                                                                                                                                                               3/15/2011
                                                                                                                                                                            DATE



                                                                                                                                                       Statement Section Below)
                                                                                                                                                                                                  EXPIRATION

                                                                                                                                                                                                  3/15/2012
                                                                                                                                                                                                                 DATE




                                                                                               POLICY RELEASE STATEMENT
                   The undersigned agrees that:




                                                                                                         0 M;;:"'
                                                                                                     ~""'T ~' .,;;~~
                                        The above referenced policy is lost, destroyed or being retained.
                                        No claims of any type will be made against the Insurahce Company, its agents or its representatives,
                                        under this policy for losses which occur after the date of cancellation shown above.

                                                A', premium "",,,,,,,,,';11 be made ln

                                                                                                                                                                      V;..-"
                                                                                                                                                                                                           03/15//1
    WITNESS                                                                                               DATE
                                                                                                                  I      XX
                                                                                                                             SIGNATURE

                                                                                                                                 SIGN
                                                                                                                                          0iMED

                                                                                                                                             BOVE
                                                                                                                                                    INSURED~                                                    'DATE



                                                                                                                  I
    WITNESS                                                                                               DATE               SIGNATURE    OF NAMED INSURED                                                       DATE




    D      LIEN HOLDER               D         MORTGAGEE               D     LOSS PAYEE                                      AUTHORIZED    SIGNATURE                                      TITLE                  DATE

                                                                                                                  1-
    I    I LIEN HOLDER               I       I MORTGAGEE               I    I LOSS   PAYEE                                   AUTHORIZED    SIGNATURE                                      TITLE                  DATE

FOR AGENCY/COMPANY USE
                               REAS[jFOR               CANCELLATION                                                                                METHOD OF CANCELLATION
-
         NOT TAKEN                               OTHER (Ident~y)
-                                                                                                                 -
 X       REQUESTED BY INSURED
                                                                                                                  ,.--    FLAT
-        REWRITIEN                                                                                                                                                         FULL TERM
         (Complete below)                                                                                                 SHORT RATE                                       PREMIUM        $
COMPANY
                                                                                                                  '--     PRO RATA
                                                                                                                                                                           UNEARNED



POLlCY
NUMBER
                                                                                          I   EFFECTIVE    DATE
                                                                                                                  h       PREMIUM CALCULATION
                                                                                                                          SUBJECT TO AUDIT
                                                                                                                                                                           FACTOR


                                                                                                                                                                           RETURN
                                                                                                                                                                           PREMIUM        $
REMARKS

 INSURED'S                REQUEST




        New York Onlt If you do not keep your auto insurance in force durina the entire registration period ~ur motor vehicle
        registration wi be suspended. If your vehicle is still uninsured after 9 dWsr ~our driver's license wdl e suspended. To
        avoid these penaltiesrJi0u must surrender ~our registrationJcertificate an p.a es before y'our insurance expires. By law
        we must report the te ination of auto insur nce coverage t the Department of Motor Ve/iicles.                            '
NAME AND ADDRESS                                                                                                      REQUESTIRELEASE DISTRIBUTION




                                                                                                                  t
 SAME         AS    ABOVE                                                                                                INSURED                        LOSS PAYEE
                                                                                                                                                  t--
                                                                                                                         MORTGAGEE                      LIEN HOLDER
                                                                                                                                                  t--
                                                                                                                         COMPANY                  t--   FINANCE   COMPANY




                     I
                                                                                                                  RRODUCER'S       SIGNATURE
                                                                                                                                                                                                     I   DATE

                                                                                                                                                                                                         8/18/2011
ACORD 35 (1197)                                                                                                                                                                @     ACORD CORPORATION 1988
INS035 (9910).02a
                                                                                                                                                                                                                                                        DATE      08/18/11
         ACORD                 TII     TEXAS PERSONAL AUTO APPLICATION
i PRODUCER                                                                                                          APPLICANT'S            NAME AND MAILING ADDRESS (Include county & ZIP+4)


\VGW INSURANCE   LLP                                                                                                FREDERIO    MAUREL                                                                                                     MAlC CODE                      FACILITY CODE

'PO BOX 969                                                                                                         LAURENCE    BETTENFELD
IVAN ALSTYNE,   TX 75495                                                                                            7500 BENELUX    CT                                                                                                     TELEPHONE NUMBER

ipH: 972-727-8949                                                                                                   PLANO    TX 75025                                                                                                      214-263-2286
                                                                                                                    cO~~Trinity                            Universal                            ~po~~~,~                                                                                        ~


             050-01435                                                                                             Insurance €ompany
 CODE:
, AGENCY CUSTOMER ID
                                                      SUBCODE:
                                                                                                                      EFFECTIVE DATE/                  EXPIRATION DATE                                                                                                           IFIRE.DIST

l
 -RE-SIDENC-E---'-CU-RR-EN-T~IDENCE
        Ii
rvri<iIYRS ADDRrpfiEvious
 CURR PREii'I'"
                                                                   IS
                                     ADDRESS (If les. than 3 ye ••.• )
                                                                                               __
                                                                        ~:.::W-:.:.:N-=E-D=--..J. L.RENTED
                                                                                     .
                                                                                                                    08/23/11
                                                                                                                                   _'_"1             08/23/12
                                                                                                                                                               GARAGE
                                                                                                                                                               ~HI
                                                                                                                                                                "
                                                                                                                                                                                            LOCATION              IF DlFF        FROM      ABOVE        (Inc     county        &~-



i 3+                 i                                                                                                                                               I
                                                                                                                                                              TOTAL NUMBER OF VEHICLES IN HOUSEHOLD'
    VEHICLE         DESCRIPTION/USE

VEt<      .YEAR                                            MAKE, MODEL AND BODY TYPE                                                            j                                            VlNlREGISTERED STATE
                                                                                                                                                                                                                                                               DATE             ••
                                                                                                                                                                                                                                                                           .P.~'W ,N~J
 1 07                     MITS          OUTLANDER                        ES/LS                      4W                                          I         ITA4MS31X27Z011719                                                                                                              \A
 2 11                     HOND          PILOT EX                        4W                                                                                5FNYF3H47BB010846                                                                                                               ~


\IE>!     COST NEW

    1 21370
                             ~~\!,~~ TERR
                              013 266
                                                     MILE 1 WAY
                                                      WKISCItL

                                                      5
                                                                  • DAYS
                                                                   WEEK

                                                                    5
                                                                              .-.
                                                                             MONTH

                                                                              4
                                                                                           USAGE


                                                                                            C
                                                                                                        ..,..
                                                                                                        FORM
                                                                                                                   MULn·
                                                                                                                    CAR


                                                                                                                    N
                                                                                                                             CAR
                                                                                                                            I'OOL

                                                                                                                             N
                                                                                                                                        GAR·
                                                                                                                                        AGED    IO£9~

                                                                                                                                                W/noe
                                                                                                                                                                              ~~\1~~ DRIVEIt DRIVE j{USE (Each
                                                                                                                                                                             10000 2
                                                                                                                                                                                                    GOVERN




                                                                                                                                                                                                     51 48
                                                                                                                                                                                                                                            veh mu     t equal 100%)
                                                                                                                                                                                                                                                                                 CLASS
                                                                                                                                                                                                                                                                          5402200lC
    2 30895                  23     266               5             5         4             C                       N        N                      q (}()n                  12000 1         51                                                                           4169200lC

                                                                                                                                               T
 va< IS~~~~T             In~~:~¥..
                                         AN11ol.0CK
                                         BRAKES 214        ANTI·THEFT DEVICES                      CREDITS AND SURCHARGESI                          ....   s~!~SIVE
                                                                                                                                                                 BELT ID~~~¥..
                                                                                                                                                                                                      AHTI-UlCK
                                                                                                                                                                                                      BJW(ES2J4          ANTI·THEFT DEVICES            CREDITS AND SURCHARGES

    1         8                             Y              P
    2         8                             Y              P
    COVERAGES/PREMIUMS                                                                                                                                                                                                                                                                  .-
                    COVERAGES                                                                              LIMITS OF LIABILITY                                                                        VEHICLE'               VEHICLE"              VEHICLE"                VEHICLE.

    SINGLE LIMIT lIABILITY (CSl)                       $                                           EAACCIDENT                                                                                         s                      $                     s                      $
    BODilY    INJURY LIABilITY                         $50000                                      EAPERSON                   $100000                                    EAACCIDENT                   $308.00 $108.00 $                                                   $
    PROPERTY DAMAGE LIABILITY                          $50000                                      EAACCIDENT                                                                                         $406.00 $138.00 ~                                                   $
    PERSONAl.. INJURY                                  $                                           EAPERSON
    PROTECTION                                         $                                           AUTO DEATH
                                                                                                                              $                                      ~?:TA,*,I ITV
                                                                                                                                                                                                      $                      s                     $                      $

    MEDICAL PAYMENTS                                   $                                           EAPERSON                                                                                           $                      $                     $                      $
                                              CSL      $                                           EAACCIDENT
    UNINSUREDI                                                                                                                                                                                        $56.00                 $56.00                $                      $
    UNDERINSURED                                BI    $50000                                       EAPERSON                   $100000                                    EAACCIDENT
    MOTORISTS
                                                PO    $50000                                       EAACCIDENT                 $ 250                                      DEDUCllBlE                   $40.00   $40.00                              $                      $
    COMPREHENSIVE                            OED      1 $500                             ~ $500                                $                                 $                                    $64.00   $44.00                              $                      $
    OTHER THAN COLLISION                     OED           $                                $                                  $                                 $                                    $        $                                   $                      $
    COlliSION                                OED      1 $500                             12 $500                               $                                 $                                    /$620.00 $284.00                             $                      s
    ACV UNLESS AMOUNT STATED                            $           $                                                               s                            $                                    $                      $                     $                      1$
    TOWING      &   LABOR                             1 $75      2 $75                                                              $                            s                                    $8.00    $8.00   $                                                  s
    TRANS EXPIRENT AI..RE                             1 $30 /dav 12 $30 /dav                                                        $           /                $                 /                  $12.00   $12.00  s                                                  Is

                                                                                                                                                                                                      $        ~                                                          $
i   ADDITIONAl.. COVERAGESIENDORSEMENTS                        (Include limit, deductible, premium)                       I POLICY FEE: $                                I    ITgJ~,!,'~R             $1514.00 $690.00                                                    $
IAU997!O                                                                                                                                                                                                  ESTIMATED TOTAL         11         DEPOSIT                      BAlANCE DUE

L.                                                                                                                                                                                                    $      2206.00                   $                          Is      2206.00
    RESIDENT             &   DRIVER      INFORMATION                (List      all       residents             &   dellendents                 licensed       or not)             and       reaular         ooeratorsl

    1#
    1 FREDERIC
              NAME (AS IT APPEARS ON LICENSE)

                 MAUREL
                                                                   SEX

                                                                    M M
                                                                            lIAR
                                                                            STAT
                                                                                     REI- TO
                                                                                     APPtJC          ~~~
                                                                                                   03/19/68
                                                                                                                              OCC

                                                                                                                           ACCO
                                                                                                                                                DATE LIC "roo
                                                                                                                                               03 84 N N N
                                                                                                                                                              ~              '=-                ~~~m~
                                                                                                                                                                                              Def     Drv:N
                                                                                                                                                                                                                         DRIVERS LICENSE fILIC STATE

                                                                                                                                                                                                                    28514434                     TX
                                                                                                                                                                                                                                                                    SOCIAL SECURITY.

                                                                                                                                                                                                                                                                  IxxxXX8902
    2 L.BETTENFELD                                                  F M                            08/21/68                ACCO                08 84 N N N                                    Det Drv:N             27846926                     TX
    3 ANAIS MAUREL                                                  F S                            04/02/95                STUD                04 11 N Y N                                    Def Drv:N             33552414                     TX

    ACCIDENTS/CONVICTIONS         eNote:  Your                              drlvlna            record           Is verified             wit h the     state    motor              vehicle         denartment)
    HAS ANY DRIVER SHOWN ABOVE HAD AN ACCIDENT                                                                                                                                                                            IF YES, INDICATE BELOW. ALSO INCLUDE
                                                                                                                                   ,.ft.            .'5     ""ADQ?            I         I    YEslxl            NO
    D~V                  DATE OF
                                                                                          DESCRIPTION OF ACCIDENT OR                            ONVICTlON                                                                        PLACE O~"TlIW
                                                                                                                                                                                                                                                        I ~~':   ~";';         AMOUNT OF
                                                                                                                                                                                                                                                                           PROPI!RTY   DAMAGe




I
L.                                    --                                                                                                                                                                                                                                                   --
    ACORD           90    TX     (2001103)                                                                     PLEASE          COMPLETE                   REVERSE             SIDE                                                     © ACORD          CORPORATION                    1981
_ADDITIONAL
  ..                        INTEREST                                     ._--_. ----.---_.                                            -                                                                                        --

                                                                                                                       I
    VEH#                         NAME AND ADDRESS                                                                                                                                            LOAN NUMBER
              f--      ADDLINT
                       LOSS PAY
    VEH#                             NAME AND ADDRESS                                                                                                                                        LOAN NUMBER
              f-- ADDLINT                                                                                              I
                       LOSS PAY
    EMPLOYMENT      INFORMATION                             (* If less    than    2 vears. orovlde  name of D~vious              emDlover       and   Drevlous     cccueatlon   under Remarks)


                                                                                                                       I
                                                                                    ADDRESS OF EMPLOYMENT                                                                   WORK PHONENUMBeR                YEA-RSWI           WI
    APPLICANrs EMPLOYER                                                                                                                                                                                     URREllPL
                                                                                                                                                                                                                         YEARS
                                                                                                                                                                                                                         PREYEUPl
    (State   natura   of business   if   self .• mployed)


    CO-APPUCANrs EMPLOYER

                                                                                                                       I
                                                                                    ADDReSS OF EMPLOYMENT                                                                   WORK PHONE NUMBeR               YEARS WI
                                                                                                                                                                                                            URRfMI'l,:
                                                                                                                                                                                                                          YEARS   WI
    IStat. nature of bUllnes,1I ,.I!-employed)                                                                                                                                                                            PREVEMPL




    PRIOR COVERAGE
    PRIORCARRIERAND PRODUCER

    ENCOMPASS
    GENERAL             INFORMATION
    EXPLAIN ALL "YES· RESPONSESIN REMARKS                                                                  YES NO EXPLAINALL "YES· RESPONSESIN REMARKS                                                                   YES NO

    1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES                                                            9. ANY HOUSEHOLD MEMBER IN MIUTARY SERVICE? (Driver number)                                            X
       NOT SOLELYOWNED BY AND REGISTEREDTO THE APPUCANT?                                                       1           10.ANY DRIVERSLICENSE BEEN SUSPENDEOIREVOKED?                                                          X
    2. ANY CAR MODIFIEDISPECIAL EQUIPMENT? (Include customized vans/pickups; indicate co I)                    X           11.ANY DRIVER HAVE PHYSICAUMENTAL IMPAIRMENT? (Lisl driver numbers)                                    X
    3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass)                                                 X           12. ANY   FINANCIAL RESPONSIBILITY FILING? (Driver number and dale of filing)                          X
    4. ANY OTHER LOSSES INCURRED (not shown in Accident/Conviction area)?                                      X           13. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY?                                             V
    5. ANY CAR KEPT AT SCHOOL?                                                                                 X           14.ANY COVERAGE DECLINED, CANCELLED, OR NON·RENEWED DURINGTHE
                                                                                                                              LAST 3 YEARS?                                                                                       X
    6.   ANY CAR PARKEDON STREET?                                                                              X
    7. ANY    OTHER AUTO INSURANCE IN HOUSEHOLD? (Include any provided by employer)                            X           IS, IS THIS BROKERED BUSINESS TO THE AGENT?                                                            X
    8. ANY OTHER INSURANCE WITH THIS COMPANY? (List policv number)                                        fx               16.HAS AGENT INSPECTED VEHICLE?                                                                        X
    REMARKS                                                                                                                               ATTACHMENTS
    TX Anti-Theft                                    Prevention                     Fee: 2.00                                                 STATE SUPPLEMENT                           MOTOR VEHICLEREPORT
                                                                                                                                              NO-FAULT APPLICATION                       PHOTOGRAPH
                                                                                                                                              YOUNG DRIVER QUESTIONNAIRE                 BILL OF SALE
                                                                                                                                              DRIVER TRAINING CERTIFICATE
                                                                                                                                              GOOD STUDENT CERTIFICATE
    FOR COMPANY USE ONLY                                                                                           I
                                                                                                                                              ANTI-THEFT DEVICE CERTIFICATE
                                                                                                                   I                          MEDICAL STATEMENT
    BINDER/SIGNATURE
                 INSURANCEBINDER       IF THE ·BINDER" BOX TO THE LEFT IS COMPLETED. THE FOLLOWING CONDITIONS APPLY;
         EFFECnve DATE                 THIS COMPANY BINDS THE KINDg;) OF INSURANCE STIPULATED ON THIS APPLICATION,
                          EXPIRATIONDATE                                                                                 THIS INSURANCE IS SUBJECT
[                                      TO THE TERMS. CONDITIONS AN LIMITATIONS OF THE POLlCY(IES) IN CURRENT USE BY THE COMPANY.
                                       THIS BINDER MAY BE CANCELLED BY TH~ INSURED BY SURRENDER OF THIS BINDER OR BY WRmEN           NOTICE TO THE
I        nME                           COMPANY STATING WHEN CANCELLATION       WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY
                         /12:01 AM
I
,
                                       BY NOTICE TO THE INSURED IN ACCORDANCE     WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHEN
                           NOON            I
                                       REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY. THE COMPANY IS ENTITLiED TO CHARGE A
                                       PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM                                                                                     IS
      / COVERAGE 15NOT BOUND           SUBJECT TO VERIFICATION    AND ADJUSTMENT    WHEN NECESSARY     BY THE COMPANY.
  NOTICE OF INSURANce INFORMATIONPRACTICeS                                                                     ~
  PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU. SUCH INFORMATION                  AS WELL AS OTHER PERSONAL
  AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES              BE DISCLOSED TO THIRD PARTIES. YOU HAVE
  THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION         IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES.       A MORE DETAILED
  DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INF6~MATION             IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR
  BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
    ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION                              FOR INSURANCE
    CONTAINING ANY MATERIALLY FALSE INFORMATION          OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION                CONCERNING    ANY FACT MATERIAL
    THERETO COMMITS A FRAUDULENT          INSURANCE ACT WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
    APPLICANrS STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO
    THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE CqMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING. IN ADDITION,IF
    THE AUTO PLAN OR COMPANY DESIGNATED IN THIS APPLICATION IS NON-STANDARD, t CERTIFY THAT I UNDERSTAND THE RATES FOR THIS COVERAGE ARE HIGHER THAN NORMAL. AND THAT
    THEY ARE ACCEPTABLETO ME AS I HAVE BEEN UNAB4E TO OBTAIN COVERAGE DESIRED THROUGH THE NORMAL INSURANCE MARKET.
                                                                                                               I

    PRODUCER'S             STATEMENT:              I CERTIFY    TO THE BEST OF MY KNOWLEDGE              AND BELIEF THAT THE SIGNATURE                       OF THE
                      APPLICANT          IS THE PERSONAL           SIGNATURE         OF THE APPLICANT.                                                                          I   HOW~~~
                                                                                                                                                                                    KNO
                                                                                                                                                                                                HAVE YOU
                                                                                                                                                                                               E APPLICANT?
    I UNDERSTAND AND ACKNOWLEDGE       THAT UNINSURED/UNDERINSURED     MOTORISTS (UMlUIM). BODILY INJURY (BI) AND PROPERTY DAMAGE (PO)
    COVERAGES HAVE BEEN EXPLAINED TO ME. I HAVE BEEN OFFERED THE OPTIONS OF SELECTING UMlUIM LIMITS EQUAL TO MY LIABILITY LIMITS.
    UM/UIM LIMITS LOWER THAN MY LIABILITY LIMITS OR TO REJECT UM/UIM BI AND/OR UM/UIM PO COVERAGES         ENTIRELY.
    1. I SELECT UNINSUREDIUNDERINSURED     MOTORISTS BODILY INJURY LlMIT(S) INDICATED IN THIS APPLICATION.                         (INITIALS)
    2. I REJECT UNINSUREDIUNDERINSURED                               MOTORISTS         BODILY INJURY AND PROPERTY              DAMAGE        COVERAGE        IN ITS ENTIRETY.                           (INITIALS)
    3. I REJECT ONLY UNINSUREDIUNDERINSURED                                      MOTORISTS   PROPERTY    DAMAGE COVERAGE                  IN ITS ENTIRETY.                                              (INITIALS)
    I UNDERSTAND AND ACKNOWLEDGE    THAT PERSONAL INJURY PROTECTION C0VERAGE HAS BEEN EXPLAINED TO ME
    AND I HAVE BEEN OFFERED THIS COVERAGE. IF I HAVE REJECTED THIS COVERAGE, MY INITIALS ARE INCLUDED HERE.                                                                                          (INITIALS)

    I UNDERSTAND THAT THE COVERAGE                                SELECTION AND LIMIT CHOICES INDICAIED HERE OR IN ANY STATE, SUPPLEMENT                                   WILL APPLY TO ALL FUTURE
    POLICY RENEWALS. CONTINUATIONS                               J ~ CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.




                                                            -V t                                    G()~I~II I                                         I
    ==t)(~~~                                                                                             ,
                                                                                                                                          PRODUCER'S
                                                                                                                                          SIGNATURIE

    ACORD90'lX'(2                               3)
USE OF CREDIT INFORMATION                    DISCLOSURE
Insurer's Name            Trinity Universal Insurante Company
Address     Customer Relations. PO. Box 3327, Fcranton, PA 18505


Telephone Number (toll free if available) _---.l8l.J7uj!=.-2L:5;L2'=-:L7o.87LJ8~------.----

We will obtain and use credit information on you or any other member(s) of your household as a part of
the insurance credit scoring process.

If you have questions regarding this disclosure, contact the insurer at the above address or phone
number. For information or other questions, contact the Texas Department of Insurance at
1-800-252-3439 or P.O Box 149091, Austin, Te as 78714.

Article 21.49-2U, Sec. 7{d), of the Texas Insura ce Code requires an insurer or its agents to disclose to
its customers whether credit information will be obtained on the applicant or insured or on any other
member(s} of the applicant's or insured's household and used as part of the insurance credit scoring
process.                                           I
If credit information is obtained or used on the applicant or insured, or on any   member of the applicant's
or insured's household, the insurer shall disclose to the applicant the name       of each person on whom
credit information was obtained or used and how each person's credit               information was used to

                                                   I
underwrite or rate the policy. An insurer may provide this information with this
notice.
                                                                                    disclosure or in a separate


Adverse effect means an action taken by an insurer in connection with the underwriting of insurance for
a consumer that results in the denial of coverage, the cancellation or nonrenewal of coverage, or the offer
to and acceptance by a consumer of a policy form, premium rate, or deductible other than the policy
form, premium rate, or deductible for which the consumer specifically applied. Credit information is any
credit related information derived from a credit report itself, o( provided in an application for personal
insurance. The term does not include information that is not credit-related, regardless of whether the
information is contained in a a credit report or in an application for insurance coverage or is used to
compute a credit score.

Credit score or insurance score is a number or rating derived from a mathematical formula, computer
application, model, or other process that is based on credit information and used to predict the future
insurance loss exposure of a consumer.


 SUMMARY OF CONSUMER PROTECTIONS CONTAINED IN ARTICLE 21.49-2U

 PROHIBITED USE OF CREDIT INFORMATION.                 n insurer may not:
 (1) use a credit score that is computed using fartors that constitute unfair discrimination;

 (2) deny, cancel, or nonrenew a policy of personal insurance solely on the basis of credit information without
 consideration of any other applicable underwriting factor independent of credit information; or

 (3) take an action that results in an adverse effect against a consumer because the consumer does not have
 a credit card account without consideration of any other applicable factor independent of credit information.




 CD-1 (ED. 11/03)                                                                                  Page 1 of2
                                        ·_ ..   -----

                                                        .'       ation or an inability to determine. credit
An insurer may not consider ~n absence of c d~r I~~:d               as a factor in underwriting or rating an
information for an applican~ for I~surance coverage
insurance policy unless the Insurer.
                                                        I .. information that: (A) is reasonably related ~o
 (1) has statistical, actuarial, 0: rea~onable )unhderwr~~~rhe absence of credit information could result In
                                                           t
 actual or anticipated loss experience, and (8 s a s
 actual or anticipated loss differences;
                                   .         .      tor :              erage or insured had neutral credit
  (2) treats the consumer as .If the. applicant or Insurance cov
  information, as defined by the Insurer, or
 (3) excludes the use of credit information as a actor in underwriting and uses only other underwriting
 criteria.

  NEGATIVE FACTORS. An insurer may not use any of the following ~s a negative fact?r in any credit
  scoring methodology or i~ revie~ing <?r?~it information to un?erwnte or rate a policy of personal
  insurance: (1) a credit inquiry that IS not initiated by the consumer,

  (2) an inquiry relating to insurance coverage, if so identified on a consumer's credit report; or

  (3) a collection account with a medical industry       ode, if so identified on the consumer's credit report.

  Multiple lender inquiries made within 30 days of a prior inquiry, if coded by the. consu~er ~eporting
  agency on the consumer's credit report as from the home mortgage or motor vehicle lendmg industry,
  shall be considered by an insurer as only one inquiry.

  EFFECT OF EXTRAORDINARY EVENTS. An insurer shall, on written request from an applicant for
  insurance coverage or an insured, provide reasonable exceptions to the insurer's rates, rating
  classifications. or underwriting rules for a consumer whose credit information has been directly influenced
  by a catastrophic illness or injury, by the death of a spouse, child, or parent, by temporary loss of
  employment, by divorce, or by identity theft. In such a case, the insurer may consider only credit
  information not affected by the event or shall assign a neutral credit score.

  An insurer may require reasonable written andlindependentlY verifiable documentation of the event and
  the effect of the event on the person's credit before granting an exception. An insurer is not required to
  consider repeated events or events the insurer reconsidered previously as an extraordinary event.

  An insurer may also consider granting an exception to an applicant for insurance coverage or an insured
  for an extraordinary event not listed in this section. An insurer is not out of compliance with any law or
  rule relating to underwriting, rating, or rate filing/ as a result of granting an exception under this article.

  NOTICE OF ACTION RESULTING IN ADVERSE EFFECT. If an insurer takes an action resulting in an
  adverse effect with respect to an applicant for insurance coverage or insured based in whole or in part on
  information contained in a credit report, the insurer must provide to the applicant or insured within 30

                                                     I
  days certain information regarding how an applicant or insured may verify and dispute information
  contained in a credit report.

  DISPUTE RESOLUTION; ERROR CORRECTION. If it is determined through the dispute resolution process
  established under Section 611(a)(5), Fair Credit Reporting Act (15 U.S.C. Section 1681i), as amended,
  that the credit information of a current insured was inaccurate or incomplete or could not be verified and
  the insurer receives notice of that determinatiorn from the consumer reporting agency or from the insured,
  the insurer shall re-underwrite and re-rate the i sured not later than the 30th day after the date of receipt
  of the notice.

  After re-underwriting or re-rating the insured, the insurer shall make any adjustments necessary within 30
  days, consistent with the insurer's underwriting and rating guidelines. If an insurer determines that the
  insured has overpaid premium, the insurer shall credit the amount of overpayment. The insurer shall
  c0":1pute the overpayment back to the shorter of the last 12 months of coverage; or the actual policy
  period.




  CD-1 (ED. 11/03)                                                                                      Page 20f2
PERSONAL INJURY   The law in Texas requires hat your policy provide Personal Injury Protection
PROTECTION        Coverage whenever bodily injury coverage is written. This coverage provides
COVERAGE          benefits for medical and funeral expenses, loss of income from employment and
                  reasonable expenses incurr d for obtaining services, as the result of a motor
                  vehicle accident sustained by you. Read your policy carefully for specific
                  details and exclusions. If you have any questions, your agent will be glad to
                  answer them.


REJECTION FORM    If you do not want Personal Injury Protection Coverage you must reject the
                  coverage in writing.    To do so, check the box and sign your name below.
                  Please return this form to your agent.


                  ~                                               ~
                         I hereby reject Personal Injury Protection

                  Signature of Named Insured®         ~~                                      _



                  Date                          Policy Number                             _




 AK 1605 (0590)
                                                     ..   ~




Kem.per
IMPORTANT NOTICE REGARDING OUR PRIVA9Y POLICY                                .
The Companies listed below have policies and practices that respect the pnvacy          .of our customers and
consumers. If you have Personal Lines Coverage with u~ or If you have a~                Insurance. transaction
involving such coverage, this ~oti~~ applies ~o you. It pertains to your nonpubhc        personal Information.
We shall refer to it as "Information In this notice.      I.                                . .
We reserve the right to revise this policy at any time. ":Ie Will send you a new         notice If changes are
 made that will result in other disclosures of your In~lormatlon.
Types of Information We May Collect
We may collect Information about you that we receive from:
    You on applications and other forms. Examples include your name, address, date of birth, phone
    number, social security and driver license num/bers;
    Your agent;
    Your transactions with our affiliates, others, or us. Examples include your policy's account balance,
    your premium payment history, and your bank account number; and
    Outside sources such as consumer           reporting agencies,   including   motor vehicle records, credit
    reports and claim history reports.
Types of Information We May Disclose, And To Whom
We may disclose all of the Information above, witm some exceptions, to other companies.
For instance, we may share your          Information with companies that perform marketing for us or with
financial institutions that have joint   marketing ag eements with us. If we do, we may disclose to those
companies all of the information          described above, although we will not disclose your non public
personal health information, without      your permission, for the sole purpose of joint marketing.
We will not share your Information with anyone else without your permission unless:
       1. They are helping us service or process a transaction, or
       2. We are otherwise permitted or required by law to do so.
Examples of others with whom we may share your Information without your permission include:

                                                     I
    People or organizations that perform a business function for us. Examples are a company that
    helps us:
        1. print payment coupons,
       2. adjust or investigate claims,
       3. program software to help us process customers' transactions; or
       4. market our own products or minimize unnecessary marketing to you.
    Your agent or broker;
    Requlatory and law enforcement        authorities, such as government offices or courts which subpoena
    records;
    Insurance support organizations      which gather data to help deter or prevent insurance crimes;
   Other insurance companies      or
                                  support organizations for an insurance transaction involving you. An
   example IS the purchase of reinsurance;
   Businesses which conduct actuarial or resea ch studies' ,
   Our affiliates, for internal or agency audits of the marketing of an insurance product or service; and
   A company that may acquire a line of business or function or book of business from us.



AK S167 (01 10)
                                                                                                  Page 1 of2
Security of Your Information
We have procedures and policies to help us protee your Information from unauthorized use or access.
At our companies, we restrict access to protected information to the employees who have a business
need for it. When we share Information with companies who work on our behalf, we protect it where
required by federal law with a confidentiality agreement. We also have physical, electronic and
procedural safeguards to guard your Information.      I
If You Are an Internet User
If you use the Internet and access the website   at       one or more of our companies,   it may have other
information on your use of that website.
STATE EXCEPTIONS
This notice is not intended for use in Arizona, California, Connecticut, Georgia, Maine, Minnesota,
Montana, Nevada, North Carolina, Ohio, Oregon 011 Virginia. If you have Personal Lines Coverage with
us in one of these states, or are involved in an ins ranee transaction involving such coverage in one of
these states, additional privacy provisions also app y. Contact the company or your agent for a copy of
the privacy policy applicable in your state.


UNITRIN AUTO AND HOME INSURANCE COMPANY, KEMPER INDEPENDENCE    INSURANCE
COMPANY, UNITRIN PREFERRED INSURANCE COMPANY, UNITRIN ADVANTAGE INSURANCE
COMPANY, TRINITY UNIVERSAL INSURANCE COMPANY, VALLEY PROPERTY & CASUALTY
INSURANCE COMPANY, VALLEY INSURANCE COMPANY, UNITRIN SAFEGUARD INSURANCE
COMPANY, UNITRIN COUNTY MUTUAL INSllJRANCE COMPANY, MERASTAR INSURANCE
COMPANY




AK 5167 (0110)                                                                                 Page2of2
     TEXAS UNINSURED            MOTORISTS            COVERAGE            SELECTION/REJECTION


     Policy Number


     Texas law permits you to make certain decisions regarding Uninsured Motorists Coverage. This document
     briefly describes this coverage and the options availa Ie.
     You should read this document carefully and contact us or your agent if you have any questions regarding
     Underinsured Motorists Coverage and your options with respect to this coverage.
     This document includes general descriptions of c0l' erage. However, no coverage is provided by this
     document. You should read your policy and review your Declarations page(s) and/or Schedule(s) for
     complete information on the coverages you are provi ed.
     Please review your policy carefully and if you wisl'l to make any change, complete and sign the form
     and return it to your agent. The options you select will apply to subsequent renewal policies unless
     we receive a written request for change from you at a later date. Coverage changes will become
     effective upon our receipt and approval of your request.

     UNINSURED MOTORISTS                COVERAGE

     Uninsured Motorists Coverage provides insurance wotection to an insured for compensatory damages
     which the insured is legally entitled to recover from the owner or operator of an uninsured motor vehicle
     because of bodily injury or property damage caused b an automobile accident. Also included are damages
     due to bodily injury or property damage that result from an automobile accident with a hit-and-run vehicle
     whose owner or operator cannot be identified.
     Effective Prior to 01-01-2011
     Unless rejected, Uninsured Motorists Coverage will be afforded at limits at least equal to: (1) split limits of
     $25,000 for each person, subject to $50,000 for eac~ accident with respect to bodily injury, and $25,000
     with respect to property damage; or (2) a combined s'ngle limit of $75,000 for each accident, but you may
     select optional higher limits.
     Effective 01-01-2011 and Later
     Unless rejected, Underinsured Motorist Coverage will be afforded at limits at least equal to: (1) split limit of
     $30,000 for each person, subject to $60,000 for eacti accident with respect to bodily injury, and $25,000

                                                                   I
     with respect to property damage; or (2) a combined single limit of $85,000 for each accident, but you may
     select optional higher limits.
     Please indicate your choice from either A. or B. as follows:




                                  Includes copyrighted material of tHe Insurance Services Office.
                                                       with its permisslon,
AK 5654 (09 10)                                    © ISO Propertie~, Inc., 2007                             Page 1 of2
   A.     Selection Of Uninsured Motorists ~overage L'mits                    do so by initialing next to the appropriate
          If you wish to. se~ectUninsured Motonst~h~~:;~~~Y ~~~;nJ~nsured Motorists Coverage limits up to
          item(s) and sIgning bel?~. Plefase note\. even though higher limits may appear below.
          the Liability Coverage limIts 0 your po ICY,             I                 . . .,             .
           (Initials)
                            I select Uninsured Motorists           overage at the   fo\\owmg "mltls).

                            (Choose one Split Limits Bodily I~ju!y op~ion AND one Pro~ert~ Damage limit
                            option, OR one Combined Sililgle Limit option from the following).


                                                                        Property                                Combined
                            Split Limits                                                                          Single
                            Bodily Injury         (Initials)   AND      Damage       OR    (Initials)
           (Initials)                                                                                             Limit

                                                                       $ *25,000                            $    *75,000
                          $ *25,000/50,000
                                                                          25,000                                  85,000
                             30,000160,000
                             50,000/100,000      ®                        50,000                                  100,000
                                                                                                                  150,000
                            100,000/300,000                              100,000
                            250,000/500,000                            **500,000                                  200,000

                            300,000/300,000                                                                       300,000

                           **500,000/500,000                                                                      325,000
                                                                                                                  400,000
                                                                                                                 **500,000

           * These limits are ONLY available until 01-01-2011
               hese limits are NOT aval ble     new business.




     B.    Rejection Of Uninsured Motorists Coverage
           If you wish to reject Uninsured Motorists Coverage, you may do so by initialing and signing below.

                                                               I
           Any rejection will apply to future renewal policies unless we receive a written request at a later date to
           add.the rejected coverage to your policy.

             (InitialS)      I reject Uninsured Motoris s Bodily Injury and Property Damage Coverage in its
                             entirety.
             (Initials)
                             I reject ~       Uninsured Motorists Property Damage Coverage in its entirety,



            Signature Of Applicant/Named         Insured                                                         Date


            Policy Number




AK 5654 (09 10)                                                                                                         Page 2 of2
                                                                                     --


                                                                                                                                                                                                            DATE
    ACORDm                     CANCELLATION                                            REQUE ~T I POLICY RELEASE                                                                                    8/18/2011
PRODUCER                                 I   Wg,N:o,   Ext):   (972)       727   -8949       I                 I      COMPANY    NAME AND ADDRESS                              NAiCCODE:

VGW/Walker                 Insurance               Agency                                                             ENCOMPASS
P.O.       Box          969


Van       Alstyne                                 TX         75495


CODE:     1119110000                                     I   SUB CODE:                                                POLICY
                                                                                                                      TYPE
~3g~8~ERID:   00059991                                                                                                           Private          Passenqer           Auto
INSURED    NAME AND ADDRESS                                                                                           CANCELLED POLICY INFORMATION
Frederic                 Maurel
Laurence                Bettenfeld                                                                                    ~~~;~R      US281376288
7500        Benelus           ct                                                                                                                               CANCELLATION        DATE           TIME
                                                                                                                              EFFECTIVE DATE AND                                                                        HAM
Plano                                             TX         75025                                                           HOUR OF CANCELLATION              08/23/2011                                                     PM




                    I
        I CANCELLATION            REQUEST (Policy attached)
                                                                                                                  I
                                                                                                     I I POLICY RELEASE (Complete
                                                                                                                                   POLICY TERM
                                                                                                                                                               EFFECTIVE

                                                                                                                                                               3/15/2011
                                                                                                                                                                            DATE



                                                                                                                                                       Statement Section Below)
                                                                                                                                                                                                  EXPIRATION

                                                                                                                                                                                                  3/15/2012
                                                                                                                                                                                                                 DATE




                                                                                               POLICY RELEASE STATEMENT
                   The undersigned agrees that:




                                                                                                         0 M;;:"'
                                                                                                     ~""'T ~' .,;;~~
                                        The above referenced policy is lost, destroyed or being retained.
                                        No claims of any type will be made against the Insurahce Company, its agents or its representatives,
                                        under this policy for losses which occur after the date of cancellation shown above.

                                                A', premium "",,,,,,,,,';11 be made ln

                                                                                                                                                                      V;..-"
                                                                                                                                                                                                           03/15//1
    WITNESS                                                                                               DATE
                                                                                                                  I      XX
                                                                                                                             SIGNATURE

                                                                                                                                 SIGN
                                                                                                                                          0iMED

                                                                                                                                             BOVE
                                                                                                                                                    INSURED~                                                    'DATE



                                                                                                                  I
    WITNESS                                                                                               DATE               SIGNATURE    OF NAMED INSURED                                                       DATE




    D      LIEN HOLDER               D         MORTGAGEE               D     LOSS PAYEE                                      AUTHORIZED    SIGNATURE                                      TITLE                  DATE

                                                                                                                  1-
    I    I LIEN HOLDER               I       I MORTGAGEE               I    I LOSS   PAYEE                                   AUTHORIZED    SIGNATURE                                      TITLE                  DATE

FOR AGENCY/COMPANY USE
                               REAS[jFOR               CANCELLATION                                                                                METHOD OF CANCELLATION
-
         NOT TAKEN                               OTHER (Ident~y)
-                                                                                                                 -
 X       REQUESTED BY INSURED
                                                                                                                  ,.--    FLAT
-        REWRITIEN                                                                                                                                                         FULL TERM
         (Complete below)                                                                                                 SHORT RATE                                       PREMIUM        $
COMPANY
                                                                                                                  '--     PRO RATA
                                                                                                                                                                           UNEARNED



POLlCY
NUMBER
                                                                                          I   EFFECTIVE    DATE
                                                                                                                  h       PREMIUM CALCULATION
                                                                                                                          SUBJECT TO AUDIT
                                                                                                                                                                           FACTOR


                                                                                                                                                                           RETURN
                                                                                                                                                                           PREMIUM        $
REMARKS

 INSURED'S                REQUEST




        New York Onlt If you do not keep your auto insurance in force durina the entire registration period ~ur motor vehicle
        registration wi be suspended. If your vehicle is still uninsured after 9 dWsr ~our driver's license wdl e suspended. To
        avoid these penaltiesrJi0u must surrender ~our registrationJcertificate an p.a es before y'our insurance expires. By law
        we must report the te ination of auto insur nce coverage t the Department of Motor Ve/iicles.                            '
NAME AND ADDRESS                                                                                                      REQUESTIRELEASE DISTRIBUTION




                                                                                                                  t
 SAME         AS    ABOVE                                                                                                INSURED                        LOSS PAYEE
                                                                                                                                                  t--
                                                                                                                         MORTGAGEE                      LIEN HOLDER
                                                                                                                                                  t--
                                                                                                                         COMPANY                  t--   FINANCE   COMPANY




                     I
                                                                                                                  RRODUCER'S       SIGNATURE
                                                                                                                                                                                                     I   DATE

                                                                                                                                                                                                         8/18/2011
ACORD 35 (1197)                                                                                                                                                                @     ACORD CORPORATION 1988
INS035 (9910).02a

								
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