APPLICATION FOR AUTOMOBILE INSURANCE

1 WESTERN GENERAL INSURANCE COMPANY5230 Las Virgenes Road, Calabasas, california 91302 APPLICATION FOR AUTOMOBILE INSURANCEPage 1 of 4 Phone: (800) 758-3311 Phone: (818) 880-5433 Fax: (818) 880-9273 PROPOSED EFFECTIVE DATE:TIME: AM PMCOVERAGE TERM:APPLICANTREGISTERED OWNER:ADDRESS:CITY:TYPE OF RESIDENCY:STATE:ZIP:LENGTH OF RESIDENCY:HOME PHONE:CELL PHONE:PRODUCERPRODUCER NAME:ADDRESS:CITY:PRODUCER CODE:STATE:ZIP:PHONE:PROOF OF INSURANCE (SR): ( california Filing Only - please attach copies) SR1P - Accident for: SR22 - All other reasons for:WORK PHONE:E-MAIL:List all drivers including applicant and household members over 14 years old.

2 If anyone is to be EXCLUDED, list on the Designated DriverExclusion section of this OF DRIVER EXACTLY AS SHOWN ON DRIVER S LICENSEFIRST NAMEMIDDLE NAMELAST NAMEDRVR#RELATIONSHIPTO APPLICANTGENDERMARITALSTATUSDATE OFBIRTH YEARS DRIVING EXPERIENCECAYRS / MODRVR#DATE FIRSTLICENSED USAYRS / MOTOTALYRS / MOCURRENT VALIDLICENSE NUMBERSTATELICENSEDPRIOR VALIDLICENSE NUMBERPRIORSTATELICENSEDSOCIAL SECURITY NUMBERDRVR#EMPLOYER NAME EMPLOYER ADDRESS, CITY, STATE, ZIPOCCUPATIONDRIVERST here is NO COMPREHENSIVE OR COLLISION COVERAGE while the insured vehicle(s) is being driven by anyone living with the applicant, unless they are namedabove and the appropriate premium is paid.

3 ALL EXCLUDED DRIVERS NAMED ON THE DESIGNATED DRIVER EXCLUSION SECTION OF THIS FORM HAVE NOCOMPREHENSIVE, COLLISION OR LIABILITY COVERAGE. IF YOU HAVE PURCHASED PHYSICAL DAMAGE COVERAGE (Comprehensive and Collision) FOR ANYOF THE LISTED VEHICLES ON THIS APPLICATION OR POLICY, REGARDLESS OF WHETHER YOU HAVE MADE A PAYMENT OR NOT, NO COVERAGE WILL BEAFFORDED FOR PHYSICAL DAMAGE TO A COVERED AUTOMOBILE IF THE DRIVER OF THE VEHICLE DID NOT HAVE A VALID DRIVER S LICENSE AT THETIME OF THE ACCIDENT OR LOSS UNLESS SAID DRIVER IS LISTED ON THE POLICY DECLARATIONS / VIOLATIONVIOLATION DATEPOINTSDRIVER NAMEP lease list below the following: DUI s within the last ten years; moving violations and license suspensions within the last three years.

4 And accidents within the last three years for which you were principally at fault that caused bodily injury or death, or over $750 ofproperty damage (you are considered to be principally at fault if your actions or omissions were at least 51% of the proximate cause ofthe accident). When you sign this APPLICATION , you certify under penalty of perjury to the accuracy of the information you have additional page(s) if HISTORY(MUST BE COMPLETED)CONVICTION DATEWGI-408B ZA REV.(12/08) SIX (6) MONTHS TWELVE (12) MONTHSAPPLICANTMILITARY(Y/N) OWN RENTINT LYRS / MOMEDALLION YES NOCOUNTRYLICENSEDPage 2 of 4 VEH#LICENSEPLATEVEH.

5 VALUE/ SYMBOLPURCHASEDATEANNUALMILEAGE1234 VEHICLE(S)YEARMAKEMODEL / BODY STYLECOMPLETE VEHICLE IDENTIFICATION NUMBER (VIN)CURRENTODOMETERCOVERAGES AND LIMITS OF LIABILITYS elect Coverages, Limits (check box) and indicate Premiums for each vehicle listedCOVERAGESLIMITSPREMIUMSMEDICAL PAYMENTSUNINSURED MOTORISTS /UNDERINSURED MOTORISTS BIUNINSURED MOTORISTS PD / CDWCOMPREHENSIVE & COLLISIONL imited to Actual Cash Value Less Deductible of:SPECIAL EQUIPMENT $ 500 $ 1,000 $ 15,000 / 30,000 $ 30,000 / 60,000 $ 500 $ 1,000 BODILY INJURY &PROPERTY DAMAGELIABILITY $ 15,000 / 30,000 / 5,000 $ 15,000 / 30,000 / 10,000 $ 30,000 / 60,000 / 15,000 $ 100,000 / 300,000 / 50,000 TOTAL VEHICLE PREMIUM (PREMIUMS REFLECT APPLICABLE DISCOUNTS)ADDITIONAL TOWING & CAR RENTAL(ALL VEHICLES MUST HAVE SAME GUIDELINES FOR ACCEPTABLE RULES)(ALL VEHICLES MUST HAVE SAME LIMITS)(ALL VEHICLES MUST HAVE SAME LIMITS) YES (UMBI COVERAGE MUST BE SELECTED)(COVERAGE MUST APPLY TO ALL VEHICLES WITHCOMPREHENSIVE & COLLISION COVERAGE) YES (COVERAGE LIMIT PER ENDORSEMENT)

6 YES (MAXIMUM AGGREGATE LIMIT $2,000)VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4$$$$$$$$DISCOUNTS: Check Box(es) if Discount(s) Applies$ Preferred Provider Organization Discount Multi-Car Discount Mature Driver Course DiscountPREMIUM SUB-TOTALPOLICY FEE (Fully Earned)SR FILING FEE ($15 Each Filing)TOTAL POLICY PREMIUMGARAGING LOCATIONGARAGING ADDRESS (STREET / CITY / STATE / ZIP)VEH#Please indicate garaging location(s) for each vehicle listed if different from applicant #POLICY INTEREST(S)SPECIAL EQUIPMENTSPECIAL EQUIPMENTVEH#Coverage for special equipment is available for an additional premium. LIST SPECIAL EQUIPMENT HERE.

7 Maximum amount of special equipment is$2,000 aggregate limit. (See Underwriting Manual for a list of acceptable special equipment)COSTP lease provide complete information Good Driver Discount Citation Free Discount Renewal Discount (WGI Auto INSURANCE Only)Full PayIf EFT is checked, insuredmust complete and submitthe Authorization for DirectDebit of Payments alongwith the APPLICATION . EFTSALVAGE(Yes / No)BUS. USE(Yes / No)ADDITIONAL INSURED (AI) AND/OR LOSS PAYEE (LP) NAME & ADDRESS AI LP AI LP AI LP AI LP AI LP AI LPCOVERAGE NOT APPLICABLE ON MEDALLIONNOT APPLICABLE ON MEDALLION17% Down + 4 Installments Total Policy Premium may be paid in full or via monthly installments which are subject to a Servicing Fee of $ per month.

8 ($ per month for Automatic CreditCard or Check Debit / $ per month for Medallion Automatic Credit Card or Check Debit).PAYMENT PLAN OPTIONS:Please select one (check box) from available payment plans below. Indicate payment amount plus applicable fee(s) here >6 - MO TERM:13% Down + 4 Installments 12-day Due Date(Medallion EFT only) Down + 5 Installments Down + 5 Installments 14-day Due Date (EFT only)Full Down + 10 Installments 12 - MO Down + 10 Installments 14-day Due Date (EFT only)12-day Due Date(Medallion EFT only) Down + 11 Installments Down + 11 Installments COVERAGE INCLUDED ON MEDALLION ONLYAPPLICABLE ON MEDALLION ONLYROAD AMERICA MEMBERSHIP INCL($72 ANNUALLY / $36 SEMI-ANNUALLY)REFER TO SEPARATE ROAD AMERICA MEMBERSHIP CONTRACTFEE DISTRIBUTED IN MONTHLY INSTALLMENTSN/AN/AN/AN/APage 3 of 4 REMARKS (attach additional pages if necessary)Ref.

9 # any driver unlicensed or does any driver have an expired or revoked driver s license?Does any driver have a suspended driver s license? If the question above was answered "yes," will an SR22 reinstate driver s license?Does any driver have a limited or restricted driver s license?Has any driver ever been convicted for driving under the influence of alcohol or drugs, driving while drinking, open bottle, possession of alcohol, drunk in auto,hit and run, reckless driving or refusal to submit to intoximeter test?Has any driver ever been convicted of any felony? (if yes, do not submit unless driver qualifies for california Good Driver Discount)Are there any motor vehicles owned or leased by applicant, spouse and residents, that are not being submitted on this APPLICATION ?

10 (if yes, describe each in remarkssection below) These vehicles are not covered in this any listed vehicles used for delivery purposes, such as pizza or newspaper delivery or for any other commercial or artisan use? (if yes, do not submit, risk isunacceptable)Does any vehicle have existing damage? (If yes, please describe damage and location of damage on vehicle in the remarks section below)Has any vehicle been salvaged?Has any vehicle been rebuilt, modified, or altered? (if yes, do not submit unless driver qualifies for california Good Driver Discount)Has any vehicle been lowered or raised? (if yes, do not submit unless driver qualifies for california Good Driver Discount)Is there any other INSURANCE policy in effect on the vehicles listed on page 2 of this APPLICATION ?