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COLLECTOR VEHICLE APPLICATION - California

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					                                                 COLLECTOR VEHICLE APPLICATION - California
 APPLICANT INFORMATION
First Name:_______________________________ M.I.: ________                               Last Name: ________________________
Mailing Address:_____________________________________________________________________________
City: ____________________________________ State: _______                               Zip: ______________________________
Home Phone: _____________________________ Business Phone: __________________________________
Fax Number: _____________________________ Email Address:                               __________________________________
Security System: __________________________ Garage Construction: _______________________________
Garaging Location (if different from above):            ______________________________________________________
Effective Date Requested: ___________________ Total Number of Collector Vehicles Owned:______________
 VEHICLE(S) TO BE INSURED*
  Model                                                        Condition     Symbol        Agreed      Modified Anti-Theft        Annual
        Make/Model/Body Type                     VIN
  Year                                                            **           **           Value        Y/N       Y/N            Miles**




*For additional vehicles please continue on a separate sheet.
** Use the Condition/Symbol/Mileage Table at the bottom of this page.

Please answer the following questions and explain “Yes” responses in the remarks section.
1. Any collector vehicle currently uninsured?...................................................................................... Yes No
2. Any collector vehicle used for racing or rallying?............................................................................ Yes   No
3. Any collector vehicle used for driving to and from work or school? ............................................... Yes               No
4. Any collector vehicle used for back-up, primary or secondary transportation? .............................. Yes                      No
5. Any collector vehicle with existing prior damage? .......................................................................... Yes     No
6. Does engine, body or drivetrain differ from car maker’s original? ................................................. Yes              No
7. Will engine, body, horsepower or drivetrain be changed? ............................................................. Yes            No
8. Any collector vehicle stored outside of the garage described above? ............................................ Yes                 No
Remarks (Explain “Yes” Responses): ____________________________________________________________
__________________________________________________________________________________________
 OPERATOR INFORMATION – List ALL licensed drivers in household and corresponding regular use vehicle.
                                          Date of                                   Regular Use Vehicle                   Operates
               Name                                     License Number
                                           Birth                                     (Year/Make/Model)               Collector Vehicle?
                                                                                                                             Yes        No
                                                                                                                             Yes        No
                                                                                                                             Yes        No
Please answer the following questions and explain “Yes” responses in the remarks section.
1. Has any operator had any accidents or moving violations in last 3 years? ....................................... Yes                   No
2. Has any operator had a suspended or revoked license or been required to file an SR-22? ............. Yes                               No
3. Has any operator over age 54 completed a Mature Driver Safety course?....................................... Yes                       No
4. Do all operators qualify for the “Good Driver” discount? .................................................................... Yes      No
5. How many licensed operators in household? .................................................................................... ___________
6. To what automobile clubs do you belong? _______________________________________________________
Remarks (Explain “Yes” Responses): ____________________________________________________________
__________________________________________________________________________________________
                                                              Symbol Table
 Symbol      Description                                                   Symbol       Description
   70        Antique/Classic and Collectible (All Years)                     76         Street Rods
   71        Customized/Modified: 1965 and newer                             77         Exotics
   72        Customized/Modified: Between 1964 and 1949                      78         Kit Cars/Replicas
   73        Customized/Modified: 1948 and older                             79         Vintage/Classic/Limited/Modified Motorcycles
                                                             Condition Table
           Show                      Excellent                     Good                         Fair                  Existing Damage
                                                           Annual Mileage Table
                0-5,000 miles                              5,001 to 10,000 miles                          10,001 miles and over

CCR102CA-0508                       Underwritten by: Markel American Insurance Company                                        Page 1 of 3
Last Name:__________________________________ First Name: ____________________________________


LIABILITY COVERAGES – Choose one limit from either Combined Single Limit or Split Limits.
         Combined Single Limit              -or-                                 Split Limits
            (Each Accident)                                    (Each Person/Each Accident/Property Damage)
   $35,000         $300,000                              $15,000/$30,000/$5,000           $50,000/$100,000/$25,000
   $50,000         $500,000                              $25,000/$50,000/$10,000          $100,000/$300,000/$50,000
   $100,000        $1,000,000                            $30,000/$60,000/$15,000

UNINSURED/UNDERINSURED MOTORISTS COVERAGE – BODILY INJURY - Choose one limit.
   Select coverage                                         - or -        Decline coverage

LIMITS: If “Combined Single Limit” is selected for Liability Coverage, the limit must be “Combined Single Limit”. If “Split Limits” is
selected for Liability Coverage, the limit must be “Split Limits”. The limit may be less than or equal to the selected Liability Coverage
limit, subject to the maximum available below. Choose one.
         Combined Single Limit                             -or-                               Split Limits
            (Each Accident)                                                            (Each Person/Each Accident)
   $30,000         $300,000                                              $15,000/$30,000              $50,000/$100,000
   $50,000         $500,000                                              $25,000/$50,000              $100,000/$300,000
   $100,000        $1,000,000                                            $30,000/$60,000

UNINSURED MOTORISTS COVERAGE – PROPERTY DAMAGE – Only available if Uninsured/Underinsured
Motorists Coverage – Bodily Injury is selected and Collision Coverage is not selected. Choose one.
    Decline coverage                               $3,500 with $0 Deductible                    $3,500 with $250 deductible

MEDICAL PAYMENTS COVERAGE – Choose one.
  Decline coverage            $1,000                                                                 $5,000

PHYSICAL DAMAGE COVERAGE – Choose one for each vehicle.
              Vehicle 1                            Vehicle 2                                                 Vehicle 3
   Comprehensive Only                   Comprehensive Only                                          Comprehensive Only
   Comprehensive and Collision          Comprehensive and Collision                                 Comprehensive and Collision
Choose one deductible for each vehicle.
              Vehicle 1                            Vehicle 2                                                   Vehicle 3
   $0 Deductible                        $0 Deductible                                               $0 Deductible
   $250 Deductible                      $250 Deductible                                             $250 Deductible
   $500 Deductible                      $500 Deductible                                             $500 Deductible

WAIVER OF COLLISION DEDUCTIBLE – Only available with Collision and if selected deductible is greater than $0. Applies
to all vehicles.
    Decline coverage          Select coverage

TRAILER COVERAGE – Only available with both Comprehensive and Collision.
  Decline coverage                    Select coverage                                          Trailer Value:




CCR102CA-0508                      Underwritten by: Markel American Insurance Company                                           Page 2 of 3
Last Name:__________________________________ First Name: ____________________________________


  CONDITIONS and WARRANTIES
I warrant that any vehicle insured under this pr ogram will be operated on a limited basis consistent with the
operation of a collectible vehicle. All drivers of the vehicles insured by this program will also own a regular use
vehicle that is used for norma l, everyday driving.
It is further understood and agreed that no coverage u nder this program will apply if any vehicle insured
hereunder is used in preparation for or participation in any race, speed or stunting contest. This includes but is not
limited to its use at a performance driving school, club or open track day, an above legal speed rally, a closed
road rally, a high speed driving event or high speed auto crossing.
I understand the restrictions and accept the terms. I understand that insuranc e is not e ective until risk is
accepted by Markel American Insurance Company and payment has been made in full.
MINIMUM EARNED PREMIUM:                $100.00 per policy on any insured requested cancellation
MINIMUM WRITTEN PREMIUM:               $100.00 per policy
WARNING: It is a crime to knowingly provide false, incomp lete or misleading information to an insurance
company for the purpose of defrauding the company. P enalties include imprisonment, nes, and denial of
insurance bene ts. Your state may have speci c      warnings against ling false claim information.
CALIFORNIA WARNING:       For your protection California law requires the following to appear on this form: Any
person who knowingly presents false or fraudulent claim for   the payment of a loss is guilty of a crime and may be
subject to nes and con nement in state prison.
Applicant Signature: __________________________________________                  Date: _____________________
Licensed Agent Signature: ______________________________________                 Date: _____________________
Agency/Brokerage: ___________________________________________                   Phone:____________________

Send c ompleted appl ication and 4 color photos to:                          POLLMAN'S INS UR A NC E AGENCY INC.
4582 Katella Ave., Los Alamitos, CA 9 0720      FAX: ( 562) 596-4178                 EMAIL: pollmanins@aol.com
PHONE: ( 562) 493-4411




CCR102CA-0508                Underwritten by: Markel      American Insurance Company                        Page 3 of 3
                                                              COLLECTOR VEHICLE
                                                           SUBMISSION REQUIREMENTS
  1923 Ford
                                                                    CALIFORNIA
Model “T” Touring
Courtesy of Pollman’s classic car collection


                               Use the following checklist when compiling documents necessary for submission.


              Application Documents : Completed and signed by the applicant and producer. Includes:
                        Application
                        Screen print from Quick Quote
                        Coverage selection/rejection forms as listed below:
                           i. CSL Policies
                                        C R 634C A C    (Not required if UM/UIM-BI is chosen equal to Liability)
                                        CR631CA         (Not required if UM-PD is chosen.)
                                        CR649CA         (Not required if UM Collision Deductible Waiver is chosen.)

                                          ii. Split Limit Policies
                                                       CR634CAS        (Not required if UM/UIM-BI is chosen equal to Liability)
                                                       CR631CA         (Not required if UM-PD is chosen.)
                                                       CR649CA         (Not required if UM Collision Deductible Waiver is chosen.)

                                         NOTE: Complete only the forms applicable to the type      of limit selected (CSL vs Split Limits)


              Regular-Use Insurance                    : Copy of the current declarations page   for regular-use vehicles for each driver
              in the household.

              Photographs : At minimum, two (2) color photos from di er ent angles. Underwriting reserves the right to
              request additional photographs to support valuat ion and condition of the Collector Vehicle.
                      Pickups – require pictures of the bed, must be in show quality.
                      Street Rod/Customized/Modi ed - require four (4) photos including: exterior, interior, engine,
                      rear with trunk open.

              Premium Payment:                     Payment for total amount sent to the Agent    listed at the bottom of the application.




20070101                                                                                                                        P a ge 1 of 1
               MARKEL AMERICAN INSURANCE COMPANY

        UNINSURED/UNDERINSURED MOTORISTS COVERAGE - BODILY INJURY
                     SELECTION/REJECTION - CALIFORNIA
                                (Split Limits)
The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance
policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also
permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a motor vehicle is operated
by a natural person or persons designated by name. Uninsured motorists coverage insures the insured, his or her heirs, or legal
representatives for all sums within the limits established by law, that the person or persons are legally entitled to recover as
damages for bodily injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an
uninsured motor vehicle not owned or operated by the insured or a resident of the same household. An uninsured motor vehicle
includes an underinsured motor vehicle as defined in subdivision (p) of Section 11580.2 of the Insurance Code.

In accordance with my California's insurance laws, I have read and understand this notice and:

         Reject Uninsured/Underinsured Motorists Coverage - Bodily Injury in its entirety.

The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance
policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also
permit the insurer and the applicant to agree to provide the coverage in an amount less than that required by subdivision (m) of
Section 11580.2 of the Insurance Code but not less than the financial responsibility requirements. Uninsured motorists coverage
insures the insured, his or her heirs, or legal representatives for all sums within the limits established by law, which the person or
persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death, to the
insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of the same
household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p) of Section 11580.2 of
the Insurance Code.

In accordance with California's insurance laws, I have read and understood this notice and:

         Select Uninsured/Underinsured Motorists Coverage - Bodily Injury at the following limits for an additional premium
         charge.
                      Limits of Coverage (per person/per accident)
                          $15,000/$30,000
                          $25,000/$50,000
                          $30,000/$60,000
                          $50,000/$100,000
                          $100,000/$300,000



         Name of Insured (Print)                                          Policy Number


         Signature of Insured                                             Date Signed
I understand and agree that I personally have made the above selection after being made aware of my choices as described above.
I understand and agree that the selection made will be applicable to the vehicles described in the policy and any substitute or
replacement vehicles. I also understand that the selection I make will apply to the entire policy term, as well as all future renewals
until I make a written request for a change in coverage from the above selection.

WARNING: If you make more than one selection, do not make any selection or fail to return this form, your policy will be
endorsed with Uninsured/Underinsured Motorists Coverage - Bodily Injury at limits equal to California's financial
responsibility limits of $15,000 per person/$30,000 per accident.

CR634CAS-0107                                                                                                             Page 1 of 1
               MARKEL AMERICAN INSURANCE COMPANY

        UNINSURED/UNDERINSURED MOTORISTS COVERAGE - BODILY INJURY
                     SELECTION/REJECTION - CALIFORNIA
                            (Combined Single Limit)
The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance
policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also
permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a motor vehicle is operated
by a natural person or persons designated by name. Uninsured motorists coverage insures the insured, his or her heirs, or legal
representatives for all sums within the limits established by law, that the person or persons are legally entitled to recover as
damages for bodily injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an
uninsured motor vehicle not owned or operated by the insured or a resident of the same household. An uninsured motor vehicle
includes an underinsured motor vehicle as defined in subdivision (p) of Section 11580.2 of the Insurance Code.

In accordance with my California's insurance laws, I have read and understand this notice and:

         Reject Uninsured/Underinsured Motorists Coverage - Bodily Injury in its entirety.

The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance
policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also
permit the insurer and the applicant to agree to provide the coverage in an amount less than that required by subdivision (m) of
Section 11580.2 of the Insurance Code but not less than the financial responsibility requirements. Uninsured motorists coverage
insures the insured, his or her heirs, or legal representatives for all sums within the limits established by law, which the person or
persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death, to the
insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of the same
household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p) of Section 11580.2 of
the Insurance Code.

In accordance with California's insurance laws, I have read and understood this notice and:

         Select Uninsured/Underinsured Motorists Coverage - Bodily Injury at the following limit for an additional premium
         charge.
                      Limit of Coverage (per accident)
                          $30,000
                          $50,000
                          $100,000
                          $300,000
                          $500,000
                          $1,000,000


         Name of Insured (Print)                                          Policy Number


         Signature of Insured                                             Date Signed
I understand and agree that I personally have made the above selection after being made aware of my choices as described above.
I understand and agree that the selection made will be applicable to the vehicles described in the policy and any substitute or
replacement vehicles. I also understand that the selection I make will apply to the entire policy term, as well as all future renewals
until I make a written request for a change in coverage from the above selection.

WARNING: If you make more than one selection, do not make any selection or fail to return this form, your policy will be
endorsed with Uninsured/Underinsured Motorists Coverage - Bodily Injury at a limit equal to California's financial
responsibility limit of $30,000 per accident.

CR634CAC-0107                                                                                                             Page 1 of 1
             MARKEL AMERICAN INSURANCE COMPANY

             UNINSURED MOTORISTS COVERAGE - PROPERTY DAMAGE
                        SELECTION/REJECTION FORM
                               CALIFORNIA

Under the California Insurance Code (Section 11580.26), it is required that we offer you the opportunity to
purchase Uninsured Motorists Coverage - Property Damage if you purchased Uninsured/Underinsured
Motorists Coverage - Bodily Injury and you have not purchased Collision Coverage.

Uninsured Motorists Coverage - Property Damage protects you for property damage to the insured motor
vehicle (not including personal property therein) caused by the owner or operator of an uninsured motor
vehicle. Such coverage is limited to loss or damage to the insured motor vehicle resulting from collision
and shall not exceed its actual cash value or $3,500, whichever is less. Property damage does not include
loss of use of the insured motor vehicle.

In accordance with California's insurance laws, I have read and understand this notice and:

        Select, for an additional premium charge, Uninsured Motorists Coverage - Property Damage.
                 Limit of Coverage
                 Actual cash value or $3,500, whichever is less

        Reject Uninsured Motorists Coverage - Property Damage in its entirety.


I understand and agree that I personally have made the above selection after being made aware of my
choices as described above. I understand and agree that the selection made will be applicable to the
vehicles described in the policy and any substitute or replacement vehicles. I also understand that the
selection I make will apply to the entire policy term, as well as all future renewals until I make a written
request for a change in coverage from the above selection.



        Name of Insured (Print)                                     Policy Number


        Signature of Insured                                        Date Signed

WARNING: You MUST complete this form if you have purchased Uninsured/Underinsured
Motorists Coverage - Bodily Injury, but have not purchased Collision Coverage. If you: a) check
more than one box; b) do not check any box; or c) fail to return this form, your policy will be
endorsed with Uninsured Motorists Coverage - Property Damage for an additional premium
charge.




CR631CA-0107                                                                                        Page 1 of 1
             MARKEL AMERICAN INSURANCE COMPANY

             UNINSURED MOTORISTS COLLISION DEDUCTIBLE WAIVER
                            REJECTION FORM
                               CALIFORNIA

I HEREBY REJECT UNINSURED MOTORISTS COLLISION DEDUCTIBLE WAIVER COVERAGE.

I have purchased both Collision Coverage and Uninsured/Underinsured Motorists Coverage - Bodily
Injury. I understand that under the California Insurance Code (Section 11580.26) Uninsured Motorists
Collision Deductible Waiver coverage is available for purchase to waive any Collision Coverage
deductible in the event of collision involving involving the insured motor vehicle and an uninsured motor
vehicle, but I reject this coverage.

In accordance with California's insurance laws, I have read and understand this notice. I understand and
agree that I personally have made the above rejection after being made aware of my choices as described
above. I understand and agree that the rejection made will be applicable to the vehicles described in the
policy and any substitute or replacement vehicles. I also understand that the rejection made will apply to
the entire policy term, as well as all future renewals until I make a written request for a change in coverage
from the above rejection.


        Name of Insured (Print)                                    Policy Number


        Signature of Insured                                       Date Signed

WARNING: You MUST complete this form if you have purchased Collision Coverage and
Uninsured/Underinsured Motorists Coverage - Bodily Injury and you wish to reject Uninsured
Motorists Collision Deductible Waiver. If you fail to return this form, your policy will be endorsed
with Uninsured Motorists Collision Deductible Waiver for an additional premium charge.

NOTE: If you have purchased Uninsured Motorists Collision Deductible Waiver, you do not need
to return this rejection form.




CR649CA-0107                                                                                       Page 1 of 1

				
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