MOPAR VEHICLE PROTECTION APPLICATION An …

1 Form Number 81-770-2100 (02/16)Page 1 of 2 MOPAR VEHICLE PROTECTION APPLICATIONAn fca us llc issued PlanPlan Number: VEHICLE AND CONTRACT HOLDER INFORMATIONVEHICLE ID NUMBERYEAR/MAKE/MODELODOMETER &TYPEMILESKMIN-SERVICE DATEPRIMARY CONTRACT HOLDER S FIRST & LAST NAME OR COMPANY _____OPTION SALE DATESECONDARY CONTRACT HOLDER S FIRST & LAST _____PRIMARY E-MAIL ADDRESSPRIMARY CONTRACT HOLDER S ADDRESSSTATEZIPPHONE NUMBERHWCPHONE NUMBERHWCCOVERAGE INFORMATIONPROGRAM NAME / TERM*OPTION CODE /DEDUCTIBLECUSTOMERPAIDAMOUNTSALESTAXTOT ALN/CFLAGPAYMENTMETHODAMOUNTDOWNAMOUNTFI NANCED____DED____DED____DED____DEDTOTALS SURCHARGES:12 MONTHS/12,000 MILESAWD/4 WDDIESELMODEL YEARSPECIALITY CLASS:123 CHECK BOXNO CHARGE FLAG:PAYMENT METHOD KEY:IF TAXDI-Dlr IncentiveA-Dlr Payment PlanR-Rapid RemitEXEMPTP-Part of PackageB-Financed w/vehicleC-CashEMPLOYEE PURCHASEYESNOFINANCE SOURCE (COMPLETE ONLY IF CONTRACT IS FINANCED WITHVEHICLE)IMPORTANT NOTICE TO CONTRACT HOLDER.

2 Your signature means the coverage and the actual plan indicated above has been reviewed by you, and if your APPLICATION is approved by fca us llc , youaccept its terms and contract is NOT required to purchase or finance a motor in the State of Florida: The rate charged for this agreement is not subject to regulation by the Florida Office of Insurance HOLDER S SIGNATUREX_____DEALER INFORMATIONDEALERSHIP NAMESELLING S-IDPHONE NUMBERSTREET ADDRESSCITY, STATE & ZIPBCDEALER CODEIMPORTANT NOTICE TO DEALER ..Your signature on this form signifies that: (1) This VEHICLE qualifies for the contract; (2) You have reviewed the coverage with the contract holder; (3) Youhave delivered a copy of this form to the contract holder for the amount you have recorded on the form; (4) You will provide service to the contract holder inaccordance with the provisions of the contract fca us llc will issue to the contract holder; (5) You have reviewed the MOPAR VEHICLE PROTECTION PlanPricing and Eligibility Guide and agree to abide by the policies and procedures specified therein; (6) You MUST enter APPLICATION information intoDealerCONNECT within 30 days of contract holder purchase.

3 (7) fca us llc may set off any money it owes you to reimburse for any claim due to breachof the foregoing representations and/or your failure to perform your obligations as fca us llc s agent with regard to this NAME _____AUTHORIZED DEALER SIGNATUREX_____DATE _____NOTETO CONSUMER: Retain this form as evidence you have applied for the coverage(s) indicated above. The dealer will transmit this information toFCAUS LLC. fca us llc will notify you of acceptance by mailing your Plan Provisions defining plan coverage. IF YOU HAVE NOT RECEIVED YOUR PLANPROVISIONS WITHIN 30 DAYS, CALL 1-800-521-9922. This document is an APPLICATION for a MOPAR VEHICLE PROTECTION plan and does not constitute acontract until accepted byFCA :#1 (BLACK) DEALERCONNECT ENTRY DOCUMENTCA License #: 0G94472#2 (GREEN) FINANCE SOURCE (IF ANY)FL License #: 65505#3 (BROWN) TO OWNERRef. 20150101#4 (BLUE) DEALER S FILEMOPAR VEHICLE PROTECTION APPLICATION An fca us llc issued Plan VEHICLE ELIGIBILITY The following are NOT eligible for MOPAR VEHICLE PROTECTION MECHANICAL COVERAGE: Vehicles registered outside of the united states , Guam and Puerto Rico; right hand drive vehicles (except vehicles manufactured by fca us llc ); motor homes; taxis or limousines (except vehicles placed in van pool service); emergency vehicles (ambulance, fire, police pursuit); vehicles used for postal service (except vehicles manufactured by fca us llc ); vehicles used for severe off-road use; vehicles converted from two- to four-wheel drive; vehicles altered or converted from the original manufacturer s specifications; vehicles not used in accordance with manufacturer s specifications for payload and/or towing capacity.

4 Vehicles equipped with a diesel engine (except vehicles manufactured by fca us llc , Ford Motor Company, General Motors and Volkswagen); vehicles that operate on other than gasoline or diesel fuel systems ( natural gas, full-electric vehicles); vehicles equipped with NorthStar engines; vehicles equipped with engines greater than 8 cylinders; vehicles with a gross weight ( ) of over 14,000 pounds; one-ton vehicles used for commercial use ( snowplows); cab and chassis vehicles ( dump trucks); vehicles where the manufacturer s warranty has been voided or restricted by the manufacturer; vehicles that have been declared to be a total loss by any insurance company, are rebuilt after being declared a total loss, or are issued a title indicating that designates it as salvage , junk , rebuilt or words of similar impact. NOTE: Special mechanical coverage is available for the following fca us llc vehicles ONLY: Police pursuit; vehicles equipped with engines greater than 8 cylinders; Ram trucks with a gross weight ( ) of over 14,000 pounds; one-ton vehicles used for commercial use ( snowplows); cab and chassis vehicles ( dump trucks); hybrid/electric vehicles.

5 COVERAGE TERMS* New VEHICLE Plans: Coverage begins on the date the VEHICLE is put into service and 0 miles. The original in-service date begins when the VEHICLE is sold as new, which is the same as the manufacturer s warranty date. When there is an existing warranty on the VEHICLE , the contract term will include the warranty period. Coverage ends at the time or mileage interval purchased, whichever occurs first. Pre-Owned VEHICLE Plans: Coverage begins on the date you purchase the plan and the mileage on the odometer at time of purchase. Coverage will end based on the time or mileage interval purchased, whichever occurs first. NOTE: New and Pre-Owned VEHICLE Plans: Alternatively, coverage under the Plan ends when the repair costs for covered component(s) exceed to VEHICLE s cash value and we issue a payment for the amount of the VEHICLE s cash value, rather than for the repair costs, which payment is the final plan benefit. IMPORTANT INFORMATION REGARDING FIRST DAY RENTAL/CAR RENTAL ALLOWANCE If included in your contract, the rental car must be obtained from a dealer or from a licensed rental agency.

6 Rental coverage is not provided where loaner VEHICLE coverage is provided by the warranty or the dealer. Rental coverage is subject to state and local laws and policies imposed by the rental agency. fca us llc is not responsible for any refusal of a rental agency to rent a VEHICLE to you. Pursuant to Washington Statute ( ): WASHINGTON DISCLOSURE NOTICE I acknowledge that I have read and understand that provisions referenced in items 1 through 6 below by initialing each provision. 1) Any material conditions that the contract holder must meet to maintain coverage under the contract including, but not limited to, any maintenance schedule to which the contract holder must adhere, any requirement place on the contract holder for documenting repair or maintenance work, any duty to protect against any further damage, and any procedure to which the contract holder must adhere for filing claims is contained in the Provision entitled YOUR ADDITIONAL RESPONSIBILITIES.

7 2) The work and parts covered by the contract are contained in the Provision entitled COVERAGE UNDER THE PLAN: WHAT IS COVERED. 3) Any time or mileage limitations are contained in the Provisions entitled WHEN PLAN COVERAGE STARTS AND ENDS. 4) The VEHICLE s IMPLIED WARRANTY OF MERCHANTABLITY NOT WAIVED: The Implied Warranty of Merchantability on the VEHICLE is not waived if the contract has been purchase within ninety (90) days of the purchase date of the VEHICLE from the dealer who also sold the VEHICLE . 5) Any exclusions of coverage are contained in the Provision entitled THE PLAN WILL NOT COVER OR APPLY TO LOSS OR EXPENSE RESULTING FROM. 6) The contract holder s rights to return the contract for a refund are contained in the Provision entitled CANCELLATION POLICY. CONTACT INFORMATION TOLL-FREE ASSISTANCE IS AVAILABLE 8:00 THRU 8:00 EST MONDAY THRU FRIDAY 9:00 THRU 5:00 EST SATURDAY 1-800-521-9922 MOPAR VEHICLE PROTECTION Box 2700 Troy, MI 48007-2700 Form Number 81-770-2100 (02/16) Page 2 of 2