ANTIQUE CLASSIC AUTO APPLICATION MINNESOTA by jolinmilioncherie

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									                                                                                                                                                         PRODUCER #

                                                                                                                                                         MARKETING CODE

                                                                                                                                                         QUOTE #
                                                           498 Kings Highway, North • P.O. Box 8343 • Cherry Hill, NJ 08002-0343
                                                               Telephone: 856-779-7212 or 800-360-2277 • Fax 856-779-7289
                                                                           http://www.americancollectorsins.com
                                                    ANTIQUE/CLASSIC AUTO APPLICATION - MINNESOTA
PLEASE PRINT                                                            Underwritten By American Security Insurance Company
LAST NAME                                                     FIRST NAME                                   MIDDLE INITIAL                             DAYTIME – TELEPHONE NUMBER

                                                                                                                                                     (           )
ADDRESS                                                       CITY                                         STATE                                      ZIP CODE



                       COMPLETE FOR ALL MEMBERS OF THE HOUSEHOLD (licensed, non-licensed and away at school)
                                                                                                                       DATES & DETAILS OF ALL AF/NAF ACCIDENTS,
                                                     DATE OF BIRTH                                                   VIOLATIONS, LICENSE SUSPENSIONS, FOR LAST 3          MARITAL
                    NAME                                                          DRIVER’S LICENSE NUMBER           YEARS. INCLUDING ANY DUI OR CARELESS DRIVING                         OCCUPATION
                                                    MO.      DAY      YR.                                                                                                 STATUS
                                                                                                                                FOR THE LAST 10 YEARS.
INSURED

SPOUSE
CHILDREN                  IF NONE                                                                                                        IF NONE

CHILDREN             PLEASE INDICATE                                                                                                 PLEASE INDICATE



     MODEL                                         BODY                                                                                                              PRINCIPAL            ODOMETER
                           MAKE                                        MODEL                      IDENTIFICATION NUMBER                      AGREED VALUE
      YR.                                          TYPE                                                                                                               DRIVER               READING

1.                                                                                                                                           $

2.                                                                                                                                           $

3.                                                                                                                                           $

 1. Are all collector cars kept in completely enclosed, locked garages?                 Yes        No      Address
 2. Are listed cars used for any purpose other than club or hobby activities or an occasional drive?                  Yes          No If yes, please explain
 3. Estimated annual mileage, car: #1                                                             #2                                                     #3
 4. Member of a car club?        Yes        No      If yes, which one?
 5. What liability limits do you carry on your family autos?       Bodily injury                       /                          Uninsured Motorists                            /
 6. List ALL other cars in your household including nonowned or company cars available for your full-time use:
      Year _______ Make_________________________                         Year _______ Make_________________________                           Year _______ Make________________________
 7. Please list Lienholder of the antique auto(s), if applicable:
 8. Do any principal operators or vehicles listed above qualify for the Accident Prevention Course or Anti-Theft Device discount(s)?                      Yes        No          If yes, attach proof.
 9. Please tell us how you learned of our program:          Broker        Friend       Car Show (name of show):_______________;                  Advertisement (specify): ____________________.


                                                                         ONE CAR                              TWO CARS                           THREE OR MORE                       LIABILITY PREMIUM

 LIABILITY includes bodily injury and property             $30,000/60,000/ $100,000 $300,000 $30,000/60,000/ $100,000 $300,000 $30,000/60,000/ $100,000 $300,000
                                                               $10,000                           $10,000                           $10,000
 damage. Select your desired limit.
                                                               $17             $18       $22           $25           $27         $33          $33             $36      $43       $

 BASIC PERSONAL INJURY PROTECTION: See                                   ONE CAR                              TWO CARS                             THREE OR MORE                     BASIC PIP PREMIUM
 back for options.
                                                                            $4.                                    $7.                                    $8.                    $
 UNINSURED/UNDERINSURED MOTORISTS: The                                   ONE CAR                              TWO CARS                             THREE OR MORE                      UM/UIM PREMIUM
 premiums shown provide the required statutory split
 limits of $25,000/50,000 Bodily Injury UM. See back for
 options.                                                                   $7.                                    $14.                                   $20.                   $
                                       PHYSICAL DAMAGE RATES PER $100 OF AGREED VALUE – NO DEDUCTIBLE
                                                                                    NO. OF     TOTAL VEHICLE
                           RATING CATEGORIES                                                                                      TYPE OF COVERAGE                                     P.D. PREMIUM
                                                                                   VEHICLES       VALUES
                                                                                              $                           x $0.60 per $100. of value comp. & coll.               $
                         25 Years Old and Older
                                                                                              $                           x $0.35 per $100. of value comp. only                  $
                                                                                              $                           x $1.50 per $100. of value comp. & coll.               $
                    20 Years Old thru 24 Years Old
                                                                                              $                           x $0.75 per $100. of value comp. only                  $
                                                                                              $                           x $1.70 per $100. of value comp. & coll.               $
                    15 Years Old thru 19 Years Old
                                                                                              $                           x $0.85 per $100. of value comp. only                  $
     Note: The physical damage rates above include $0 deductible safety glass coverage.
     $30.00 minimum earned premium                                      Windshields will be replaced with safety glass.                                                    All premiums are annual.
                                                                                                                                                                                     SURCHARGE
                                                                                         Minnesota Auto Theft Prevention Surcharge:
                          (A $1.00 per vehicle charge for every 12-month period of comprehensive coverage is required by Minnesota.) $
 Physical Damage Coverage includes Inflation Guard; Spare Parts Coverage (up to $500); Automatic Coverage for TOTAL ANNUAL PREMIUM
 newly purchased, qualifying vehicles (up to $25,000); and Emergency Towing ($25).                            $



AS8268MNA-0402                                              IMPORTANT! SEE BACK FOR SIGNATURES & OPTIONS                                                                                 Designed By: RMA
 Fraud Notice: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 such person to criminal and substantial civil penalties.


 Limitations of Use: Insured car(s) must be used primarily for club/hobby activities, but may also be used occasionally for pleasure drives that do not include general
 transportation. Collector cars cannot be used as temporary substitutes for a disabled and/or out-of-service and/or otherwise unavailable family car, nor for any timed or racing
 event. Your signature below attests to your understanding of the foregoing. Please be sure to include a color photograph of each car and a check for the total premium. Note:
 Photos become the property of American Collectors and will not be returned. Coverage will begin upon American Collectors’ acceptance of the risk. There is no coverage until
 the Producer or Applicant is so advised by American Collectors. Please allow 12-14 days for processing.

PROPOSED EFFECTIVE DATE NAMED INSURED’S SIGNATURE                            TODAY’S DATE                PRODUCER’S SIGNATURE                             TODAY’S DATE


  Mo.     Day       Yr.
                             X                                                       /         /         X                                                         /       /
                                                                IMPORTANT
                                                UNINSURED/UNDERINSURED MOTORISTS COVERAGE

   Minnesota law requires that we offer you Uninsured and Underinsured Motorists (UM/UIM) coverage limits at least equal to the state’s
   statutory minimum of $25,000/50,000 split limits. You cannot select UM/UIM limits higher than your liability limits. This coverage cannot
   be rejected.
                   UNINSURED/UNDERINSURED MOTORISTS COVERAGE SELECTION – PLEASE CHECK ONE BOX BELOW
                                                                                                                           Premium
        Limit of Coverage                                                                           One Car                Two Cars                   Three or More
        $ 25,000/50,000                                                                                 $ 7                    $14                        $ 20
        $ 30,000/60,000                                                                                 $10                    $20                        $ 30
        $100,000 CSL                                                                                    $21                    $42                        $ 63
        $300,000 CSL                                                                                    $42                    $84                        $126
   I understand that the selection I checked above will remain in force until a named insured rescinds it in writing and notifies his/her
   agent (or company) to that effect.
   SIGNATURE OF NAMED INSURED                                                                                                                  DATE

   X                                                                                                                                                      /            /
   CSL = Combined Single Limit

                                                        PERSONAL INJURY PROTECTION OPTIONS

   Minnesota allows you to stack Personal Injury Protection Coverage limits if you insure more than one vehicle. Stacking means that you
   can multiply the limit of liability of your Personal Injury Protection Coverage by the number of vehicles that you insure. Electing this
   option will result in an increase in your Personal Injury Protection premium. Please check the appropriate box below.
                                                                  Personal Injury Coverage Stacking
        I want Personal Injury Protection coverage stacking. (A charge of $22 per car insured on this policy will be added to the charge for
        the Personal Injury Protection coverage that you have selected.)
        I do not want Personal Injury Protection coverage stacking.
   In addition, Named Insureds and relatives age 65 or older may elect to exclude the work loss benefits provided by Personal Injury
   Protection Coverage if they have no expectation of actual income loss. This option can be elected to apply only to the Named Insured(s),
   or to the Named Insured(s) and his or her relatives. Selection of this option will reduce Personal Injury premiums to those shown
   below. Please check the appropriate box below.
                                                                                                                           Premium
        Work Loss Exclusion Applies to:                                                             One Car                Two Cars                   Three or More
        Named Insured(s) only:                                                                        $3.40                  $5.95                         $6.80
        Named Insured(s) and relatives:                                                               $3.20                  $5.60                         $6.40
        I do not wish to exclude Personal Injury Protection work loss benefits.

   SIGNATURE OF NAMED INSURED                                                                                                                  DATE

   X                                                                                                                                                      /            /



        American Collectors has other insurance programs dedicated to Antique and Classic Boats, and Collectibles.
                                   For details or an application, call 1(800) 360-2277.



AS8268MNA-0402

								
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