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MODIFIED VEHICLE APPLICATION - FLORIDA Underwritten By

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MODIFIED VEHICLE APPLICATION - FLORIDA Underwritten By Powered By Docstoc
					                                                                                                                                                    PRODUCER #________________________

                                                                                                                                                    MARKETING CODE ___________________

                                                                                                                                                    QUOTE #____________________________
                                                                                                                                                                           A087782
                                                                                                                                                    AGENT’S LICENSE #: _________________
                                                           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
                                                MODIFIED VEHICLE APPLICATION - FLORIDA
PLEASE PRINT                          Underwritten By American Bankers Insurance Company of Florida
LAST NAME                                                       FIRST NAME                              MIDDLE INITIAL                              DAYTIME TELEPHONE NUMBER

                                                                                                                                                    (           )
ADDRESS                                                         CITY                                    STATE               ZIP CODE                EMAIL ADDRESS



                       COMPLETE FOR ALL MEMBERS OF THE HOUSEHOLD (licensed, non-licensed and away at school)
                                                        DATE OF BIRTH                                               DATES & DETAILS OF ALL ACCIDENTS, VIOLATIONS,
                                                                                                                    LICENSE SUSPENSIONS, FOR LAST 3 YEARS. ALSO          MARITAL
                     NAME                                                        DRIVER’S LICENSE NUMBER             COMPLETE FOR ANY DUI OR CARELESS DRIVING,                      OCCUPATION
                                                     MO.     DAY       YR.                                                                                               STATUS
                                                                                                                               REGARDLESS OF YEAR.
INSURED                                                                                                                                   IF NONE

SPOUSE                                                                                                                              PLEASE INDICATE
CHILDREN                 IF NONE

CHILDREN            PLEASE INDICATE

                                                                       COLLECTOR VEHICLE INFORMATION
  MODEL                                 BODY                                                                                                                   PRINCIPAL            ODOMETER
                    MAKE                                   MODEL                 VEHICLE IDENTIFICATION NUMBER                     AGREED VALUE
  YEAR                                  TYPE                                                                                                                    DRIVER               READING

 1.                                                                                                                            $
 2.                                                                                                                            $
 3.                                                                                                                            $
 1. Are all collector vehicles kept in an enclosed, locked and private garage?            Yes       No Address __________________________________________________________
 2. Are listed vehicles used for any purpose other than club or hobby activities or an occasional drive?             Yes      No If yes, please explain _____________________________
 3. Estimated annual mileage, collector vehicle: #1 ______________________________ #2 _______________________________ #3 _______________________________
 4. Member of a local car club?          Yes        No If yes, which one? ______________________________________________________________________________________
 5. Are listed vehicles used for any type of speed or timed event?               Yes    No      If yes, please explain ________________________________________________________
 6. Please list Lienholder of the modified vehicle, (if applicable): ___________________________________________________________________________________________
 7. List ALL family cars in your household including non-owned or company cars available for your full-time use:
      Year__________ Make________________________                      Year__________ Make____________________________                     Year__________ Make_______________________
 8. What liability limits do you carry on your family autos? Bodily injury $ ________________ / $ ______________ Uninsured Motorists $_______________ / $ _______________
                                                                                       LIABILITY RATES
                                                          ONE VEHICLE                           TWO VEHICLES                         THREE OR MORE                           LIABILITY PREM.
                                                $10,000/20,000/                        $10,000/20,000/                       $10,000/20,000/
LIABILITY includes bodily injury and               $10,000          $100,000              $10,000         $100,000              $10,000         $100,000
property damage. Select your desired limit.          $36                   $60               $54              $90                   $70                 $118         $
PROPERTY DAMAGE LIABILITY
ONLY: $10,000                                                 $36                                    $54                                      $70
                                                                                                                                                                         PERSONAL INJURY PREM.
PERSONAL INJURY PROTECTION                     Please refer to the Florida Personal Injury Selection Form for available coverage limits and premiums.
                                               Please complete, sign, and attach it to this application.                                                             $
                                                                                                                                                                              UM/UIM PREM.
                                               Please refer to the Florida Uninsured Motorist Selection form for available coverage limits and premiums.
UNINSURED/UNDERINSURED
                                               Please complete, sign, and attach it to this application.                                                 $
                                                       PHYSICAL DAMAGE RATES PER $100 OF AGREED VALUE
Physical Damage Coverage includes Inflation Guard; Spare Parts Coverage (up to $500); 30-days Automatic Coverage for newly purchased, qualifying vehicles
(up to $25,000); and Emergency Towing Reimbursement ($25). See reverse for additional towing & labor options. Please refer to Policy for complete coverage
descriptions and limitations.
                                DEDUCTIBLES          NUMBER OF                   TOTAL                          COMPREHENSIVE & COLLISION                                      PREMIUM
                                                      VEHICLES               VEHICLE VALUES
       Select Your                      $0                             $                                        X   $2.20   PER    $100   OF VALUE                   $
        Desired                      $250                              $                                        X   $1.90   PER    $100   OF VALUE                   $
       Deductible                    $500                              $                                        X   $1.60   PER    $100   OF VALUE                   $
                                    $1,000                             $                                        X   $1.30   PER    $100   OF VALUE                   $
$50.00 minimum written premium                                                                                                                                      All premiums are annual.
Comprehensive only coverage is available. Please call American Collectors for rates (800) 360-2277.

TOWING & LABOR FOR COLLECTORS (TLC) PLAN                                                                   SILVER                     $9.95 per policy
                                                                                                           GOLD PLAN                 $24.95 per policy
Plan applies to all vehicles on the policy. See reverse for coverage details.                              PLATINUM PLAN             $34.95 per policy
                                                                                                                                                                     $

INCREASED SPARE PARTS COVERAGE (SEE REVERSE FOR DETAILS)                                                   $1,000                         $1,500                     $

                                                                                                                             TOTAL ANNUAL PREMIUM $



M1963FLM-0108                                                          IMPORTANT! SEE OVER FOR SIGNATURES                                                                            Designed By: NS
                                                       ADDITIONAL COVERAGE OPTIONS
                                              TOWING & LABOR FOR COLLECTORS (TLC) PLAN
                                                 Emergency Expense Coverage Endorsement
This optional coverage is designed for the insured whose collector vehicle has an emergency condition that occurs away from
the garaging address and should not be construed as a repair or maintenance service. It reimburses the insured for the expenses
described when an emergency condition occurs to a covered auto.

                      Silver Plan                                      Gold Plan                                          Platinum Plan

              $100 Emergency Towing                              $150 Emergency Towing                                 $250 Emergency Towing
              $50 Roadside Assistance                            $100 Roadside Assistance                              $150 Roadside Assistance
              $50 Emergency Lockout                              $50 Emergency Lockout                                 $50 Emergency Lockout
              Lost Key Return Service                            Lost Key Return Service                               Lost Key Return Service
                                                                 $10,000 Accidental Death and                          $20,000 Accidental Death and
                                                                 Dismemberment                                         Dismemberment
                                                                 $250 Emergency Travel                                 $500 Emergency Travel
                                                                 Expense                                               Expense
                                                                 $2,500 Theft Reward                                   $5,000 Theft Reward
                                                                 $250 Personal Effects                                 $500 Personal Effects
                                                                 $100 Ambulance Assistance                             $250 Ambulance Assistance
                                                                 $100 Car Show Expenses                                $150 Car Show Expenses
                                                                                                                       $5,000 Bail Bond
                                                                                                                       $1,000 Legal Defense Benefit
                                                                                                                       $1,000 Hit and Run Reward
                                                                                                                       TrailerGuard $150 each
                                                                                                                       disablement

                                                  SPARE PARTS COVERAGE
We will pay up to $500 for direct and accidental loss to spare parts and accessories to your covered auto. The policy for which
you are applying automatically provides $500 of coverage. You may purchase an additional $500 or $1,000 of coverage.

                                                              DISCOUNTS AVAILABLE

1. Is any vehicle equipped with:          air bags         anti-lock brakes          anti-theft devices           VIN etching?

2. Has a principal operator completed an approved accident prevention course?        Yes      No *If yes, attach proof. Premium will be adjusted accordingly.


                                                     IMPORTANT! PLEASE READ AND SIGN
Florida Fraud Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Limitations of Use: Insured vehicle(s) must be used primarily for club/hobby activities but may also be used occasionally for pleasure drives. Pleasure drives
do not include general transportation. Collector vehicle(s) cannot be used as temporary substitutes for a disabled and/or out-of-service and/or otherwise
unavailable family vehicle, nor for any timed racing event. This policy has a $50 minimum written premium. Your signature below attests to your understanding
of the foregoing. Please be sure to include a color photograph of each vehicle 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.
PROPOSED EFFECTIVE     NAMED INSURED’S SIGNATURE        TODAY’S DATE      PRODUCER’S NAME                 PRODUCER’S SIGNATURE               TODAY’S DATE
DATE                                                                      (PLEASE PRINT)


  Mo.   Day     Yr.    X                                     /     /                                      X                                       /     /
              American Collectors has other insurance programs dedicated to Collector Motorcycles and other Collectibles.
                For details or an application, call 1 (800) 360-2277 or visit our website at www.AmericanCollectors.com.




M1963FLM-0108

				
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