NEW YORK PERSONAL AUTO APPLICATION - ACORD

1 ACORD 90 NY (2015/12)ADDITIONAL GARAGING ADDRESS(ES)TAX TERRITORYINDICATE IF MAILING ADDRESS IS GARAGING ADDRESSCARRIERNAIC CODEPOLICY #:PLANPAYMENT PLANTO APPLMAIL POLICYTO AGENTMAIL POLICYAGENCYDIRECTEXPIRATION DATEEFFECTIVE DATEAPPLICANT'S NAME AND MAILING ADDRESS (Include county & ZIP+4)ACCT #:TELEPHONE NUMBERTAX TERRZIP + 4 STATECOUNTYCITYSTREETLOCZIP + 4 STATECITYRENTEDOWNEDCURRENT RESIDENCE ISPREVCURRYRS AT ADDRPREVIOUS STREET ADDRESS (If less than 3 years)RESIDENCENAME:CONTACT(A/C, No, Ext):PHONE(A/C, No):FAXAGENCYSUBCODE:CODE:AGENCY CUSTOMER ID:E-MAILADDRESS:NEW york PERSONAL auto APPLICATIONDATE (MM/DD/YYYY)The ACORD name and logo are registered marks of ACORD 1981-2015 ACORD CORPORATION. All rights be added to the total premium for each vehicle* Motor Vehicle Law Enforcement Fee, as required by New york law,$$$$%$$$OPTIONSDEDUCTIBLELIMIT APPLIES TOLIMITDESCRIPTIONCODE$FG$FG$FG$FG$$$$CO LLISIONDED$/$/$/$/TRANS EXP / RENTAL RE$$$$TOWING & LABOR$$$$$$$$N / AN / AN / AN / A$$$$ACV UNLESS AMOUNT STATED$$$$$$$$$EA PERSON$EA ACCIDENT$EA PERSON$EA ACCIDENT$$$$$EA PERSONMEDICAL PAYMENTSPROPERTY DAMAGE LIABILITY$EA ACCIDENT$$$$$$$$EA ACCIDENT$EA PERSON$BODILY INJURY LIABILITYSINGLE LIMIT LIABILITY (CSL)$EA ACCIDENT$$$$COVERAGESLIMITS OF LIABILITYVEHICLE #VEHICLE #VEHICLE #VEHICLE #COVERAGES / PREMIUMSSUPPLEMENTARY UM/UIM (SUM)

2 STATUTORY UMBI$$$$SUPPLEMENTAL SPOUSAL LIABILITYNOT INCLUDEDINCLUDED$BENDEATH$EXPOTHER$LOSSW ORK$$NAMED INSURED AND RELATIVESNAMED INSURED ONLYY / NDEDUCTIBLE$$OBELPERSONAL INJURY PROTECTIONADDITIONALMED EXP ELIMINATIONWORK LOSS COORDINATIONPERSONAL INJURY PROTECTION$$$$$$$$$$$$$$$$GF$GF$GF$GF$CO MPREHENSIVE / OTCDEDSTATEREGVEHLOCSYMCOLLOTC SYMCOMPCLASSDEVICESANTI-THEFTCREDITS ANDSURCHARGESSEAT BELTDRV/BOTHPASSIVEAIRBAGVEHANTI-LOCKBRA KES 2/4 CLASSDEVICESANTI-THEFTCREDITS ANDSURCHARGESSEAT BELTDRV/BOTHPASSIVEAIRBAGVEHANTI-LOCKBRA KES 2/4 TOTAL NUMBER OF VEHICLES IN HOUSEHOLD:VEHICLE DESCRIPTION / USEREG TO DRV #BODY TYPEMODELYEARMAKEVINHP/CCDATELEASEDDATEP URCHNEW/USEDVEHAGE GRPREADINGMILEAGECOST NEWSYMBOLTERRODOMETERANNUALDRIVER USE % (Each veh must equal 100%)MILE 1 WAYWK/SCHL# DAYSWEEK# WKSMONTHUSAGEPER-FORMMULTI-CARCARPOOLGAR CODEGOVERNDRIVERPage 1 of 4$$$$TOTAL PERVEHICLE *ESTIMATEDTOTAL: $POLICYFEE: $PREMIUMDEPOSIT: $ ACORD 90 NY (2015/12)NAME AS IT APPEARS ON REGISTRATIONVEH #NAME AS IT APPEARS ON REGISTRATIONVEH #WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY ANDREGISTERED TO THE APPLICANT?

3 / NASSIGNED RISK?PRIOR COVERAGEPRIOR CARRIER# OF YEARSPRIOR POLICY NUMBERWITH COMPANYPRIOR PRODUCEREXPIRATION DATEOWNERREGISTRANTLIENHOLDERLOSS PAYEEADDL INSLOAN NUMBERVEH #:NAME AND ADDRESSOWNERREGISTRANTLIENHOLDERLOSS PAYEEADDL INSLOAN NUMBERNAME AND ADDRESSVEH #:ADDITIONAL INTERESTOR BEEN CONVICTED OF A MOVING VIOLATION WITHIN THE LAST 39 MONTHS?HAS ANY DRIVER SHOWN ABOVE HAD AN ACCIDENT, REGARDLESS OF FAULT,Attach ACORD 99, Accidents / Convictions Schedule, if more space is requiredACCIDENTS / CONVICTIONS (Note: Your driving record is verified with the state motor vehicle department and other insurers)IF YES, INDICATE BELOW. ALSO INCLUDE COMPREHENSIVE INSURANCE / NY / NAMOUNT OFBI OR DEATHPLACE OFDATE OFDRV#ACCIDENT / CONVICTIONDESCRIPTION OF ACCIDENT OR CONVICTIONACCIDENT / CONVICTIONPROPERTY DAMAGE4.

4 $COSTDESCRIPTION$DRV #DRV #COSTDESCRIPTIONANY OTHER LOSSES NOT SHOWN IN THE ACCIDENTS / CONVICTIONS SECTION THAT WERE INCURRED DURING THE TIME PERIOD SPECIFIED INTHAT SECTION?POLICY NUMBERNAIC #CARRIERNAMED INSUREDMODELMAKEYEAR5. ANY OTHER auto INSURANCE IN HOUSEHOLD? (Include any provided by employer)VEH #VEH #DESCRIPTIONDESCRIPTION3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass)VEH #VEH #$COSTDESCRIPTION$COSTDESCRIPTION2. ANY CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans / pickups)Y / NEXPLAIN ALL "YES" RESPONSESGENERAL INFORMATIONEMPLOYMENT INFORMATION (* If less than 2 years, provide name of previous employer and previous occupation under Remarks)ADDRESS OF EMPLOYMENTWORK PHONE NUMBER* YEARS W/CURR EMPLYEARS W/PREV EMPL(State nature of business if self-employed)APPLICANT'S EMPLOYERCO-APPLICANT'S EMPLOYER(State nature of business if self-employed)PREV EMPLYEARS W/CURR EMPL* YEARS W/WORK PHONE NUMBERADDRESS OF EMPLOYMENTSTATELICDATE LICACC PREVCSE DATEDRIVERS LICENSE #SOCIAL SECURITY #STDT>100 GOODSTDTDRVTRAIN#OCCUPATIONREL TOAPPLICMARSTATLAST NAMEMIDDLE NAMEFIRST NAMENAME (AS IT APPEARS ON LICENSE)DATE OF BIRTH#SEXRESIDENT & DRIVER INFORMATION [List all residents & dependents (licensed or not)]

5 And regular operators]AGENCY CUSTOMER ID:Page 2 of 4 LENDER'S LOSS PAYABLELENDER'S LOSS PAYABLEACORD 90 NY (2015/12)XPage 3 of 4 STATE SUPPLEMENTBILL OF SALEPHOTOGRAPHMOTOR VEHICLE REPORTMEDICAL STATEMENTANTI-THEFT DEVICE CERTIFICATEGOOD STUDENT CERTIFICATEDRIVER TRAINING CERTIFICATEYOUNG DRIVER QUESTIONNAIREREMARKS / ATTACHMENTS ( ACORD 101, Additional Remarks Schedule, may be attached if more space is required)PERSON COVEREDNAME OF PLANPERSON COVEREDNAME OF PLANANY APPLICANT COVERED BY A WAGE CONTINUATION PLAN? OF SPECIAL EQUIPMENT IN VEHICLEDRV #ANY DRIVER HAVE A PHYSICAL IMPAIRMENT THAT WOULD AFFECT THE ABILITY TO DRIVE? #ANY DRIVER UNDERGOING A COURSE OF MEDICAL TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT THAT WOULD AFFECT THE ABILITY TO DRIVE? DATEREASON FOR FILINGDRV #ANY FINANCIAL RESPONSIBILITY FILING?

6 INSURANCE BEEN TRANSFERRED WITHIN THE AGENCY? DECLINED, CANCELLED, OR NON-RENEWEDDRV #ANY COVERAGE DECLINED, CANCELLED, OR NON-RENEWED DURING THE LAST THREE (3) YEARS? THIS BROKERED BUSINESS TO THE AGENT? AGENT INSPECTED VEHICLE? # ANY APPLICANT OR DRIVER HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY, JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?EXPLANATIONDRV #HAS ANY NAMED INSURED DRIVEN WITHOUT LIABILITY INSURANCE DURING ANY PART OF THE LAST SIX (6) MONTHS? OF INSURANCETYPE OF INSURANCEPOLICY NUMBERPOLICY NUMBER6. ANY OTHER INSURANCE WITH THIS COMPANY?DATEREINSTATEMENTEXPLANATIONEnd Date:Start Date:SUSPENSION PERIODDRV # DRIVERS LICENSE BEEN SUSPENDED / REVOKED?VEH AT BASE (Y / N)BASE LOCATIONRANKBRANCHDRV # HOUSEHOLD MEMBER IN MILITARY SERVICE?

7 Y / NEXPLAIN ALL "YES" RESPONSESGENERAL INFORMATION (continued)AGENCY CUSTOMER ID:IF YOU HAVE PURCHASED RENTAL VEHICLE REIMBURSEMENT COVERAGE AND YOUR VEHICLE IS DAMAGED AND ISTEMPORARILY OUT OF SERVICE DUE TO A LOSS COVERED UNDER YOUR POLICY, NEW york LAW STATES THAT YOU HAVETHE RIGHT TO UTILIZE ANY RENTAL VEHICLE COMPANY, RENTAL VEHICLE LOCATION OR A PARTICULAR CONCERN OF ( ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ACORD 90 NY (2015/12)Page 4 of 4I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEFTHAT THE SIGNATURE OF THE APPLICANT IS THE PERSONALSIGNATURE OF THE 'S STATEMENT:HOW LONG HAVEYOU KNOWN THEAPPLICANT?THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BYWRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:COVERAGE IS NOT BOUNDNOON12:01 AMTHIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICYCONDITIONS.

8 THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY,THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THECOMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION . THISINSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) INCURRENT USE BY THE DATEEFFECTIVE DATEINSURANCE BINDERAGENCY CUSTOMER ID:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES ANAPPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALSFOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES NOT TO EXCEED FIVETHOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH 'S SIGNATURENATIONAL PRODUCER NUMBERAPPLICANT'S SIGNATUREDATEAPPLICANT'S STATEMENT.

9 I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THEINFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THISINFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM ADDITION, IF THE auto PLAN OR COMPANY DESIGNATED IN THIS APPLICATION IS NON-STANDARD, I CERTIFY THAT IUNDERSTAND THE RATES FOR THIS COVERAGE ARE HIGHER THAN NORMAL, AND THAT THEY ARE ACCEPTABLE TO ME AS IHAVE BEEN UNABLE TO OBTAIN COVERAGE DESIRED THROUGH THE NORMAL INSURANCE HAVE HAD STATUTORY UNINSURED MOTORISTS AND SUPPLEMENTARY UNINSURED / UNDERINSURED MOTORISTS (SUM)COVERAGE INCLUDING THE AVAILABLE OPTIONS AND LIMITS EXPLAINED TO ME.

10 I UNDERSTAND THAT THE COVERAGESELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE RENEWALS, CONTINUATIONS AND CHANGES INMY POLICY UNLESS I NOTIFY YOU OTHERWISE IN / SIGNATURECOPY OF ACORD 38 NY, NOTICE OF INSURANCE INFORMATION PRACTICES HAS BEEN GIVEN TO THE CREDIT REPORT OR OTHER INVESTIGATIVE REPORT ABOUT YOU MAY BE REQUESTED IN CONNECTION WITH THISAPPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. IN CONNECTION WITH THIS INSURANCE,WE MAY REVIEW YOUR CREDIT REPORT OR OBTAIN OR USE A CREDIT-BASED INSURANCE SCORE BASED ON INFORMATIONCONTAINED IN THAT REPORT. AN INSURANCE SCORE USES INFORMATION FROM YOUR CREDIT REPORT TO HELP PREDICTHOW OFTEN YOU ARE LIKELY TO FILE CLAIMS AND HOW EXPENSIVE THOSE CLAIMS WILL BE.