PERSONAL AUTO POLICY CHANGE REQUEST

1 PERSONAL AUTO POLICY CHANGE REQUESTVEHICLE DESCRIPTION/USEGARAGE LOCATION (If different than mailing address)VEHICLE COVERAGES/PREMIUMSGENERAL INFORMATION (Explain all "yes" responses in remarks)ACORD 71 (1/97)cOACORD CORPORATION 1997 DATE (MM/DD/YY)PRODUCERPHONE(A/C, No, Ext):CODE:SUBCODE:AGENCY CUSTOMER ID:COMPANYNAIC CODE:NAMED INSUREDATTENTION:POL#:ACCT#:INSURED S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGEDEFFECTIVE DATE OF CHANGEINCEPTION DATE OF POLICYEXPIRATION DATECHANGE BILLING PLAN TO:PERMISSIBLE "TYPE OF CHANGE " CODES:(A) ADD, (C) CHANGE , (D) DELETEDIRECTAGENCYTYPE OFCHANGEVEH#YEARMAKE, MODEL AND BODY TYPEVIN/REGISTERED STATEHP/CCDATEPURCHNEW/USEDCOST NEWSYMBOLAGE GRPTERRMILE 1 WAYWK/SCHL# DAYSWEEK# WKSMONTHUSAGEPER-FORMMULTI-CARCARPOOLGAR -AGEDODOMETERREADINGANNUALMILEAGEGOVERND RIVERDRIVER USE % (Each veh must equal 100%)CLASSPASSIVESEAT BELTAIRBAGDRV/BOTHANTI-LOCKBRAKES 2/4 ANTI-THEFT DEVICESCREDITS AND SURCHARGESTYPE OFCHANGEVEH#IF A VEHICLE IS BEING ADDED, ANSWER QUESTIONS 1-5 YES NO IF A DRIVER IS BEING ADDED, ANSWER QUESTIONS 6-10 YES NOREMARKS1.

2 WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLESNOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT?2. ANY CAR MODIFIED/SPECIAL EQUIPMENT? (Include customized vans/pickups)3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass)4. ANY CAR KEPT AT SCHOOL?5. ANY CAR PARKED ON STREET?6. ANY HOUSEHOLD MEMBER IN MILITARY SERVICE? (Driver number)7. ANY DRIVERS LICENSE BEEN SUSPENDED/REVOKED?8. ANY DRIVER HAVE PHYSICAL/MENTAL IMPAIRMENT?9. ANY FINANCIAL RESPONSIBILITY FILING? (Driver number and date of filing)10. ANY coverage DECLINED, CANCELLED OR NON-RENEWED DURING THELAST 3 YEARS? NOT APPLICABLE IN MOCOVERAGESTYPE OFCHANGEVEH #:SINGLE LIMIT LIAB (CSL)BODILY INJURY LIABPROPERTY DAMAGE LIABNO FAULTCOVERAGESMEDICAL PAYMENTSUNINSUREDMOTORISTCSL/BIPDUNDERIN SUREDMOTORISTCSL/BIPDCOMPREHENSIVECOLLIS IONACV UNLESS AMT STATEDTOWING & LABORTRANS EXP/RENTAL RE$EA ACCIDENT$EA PERSON$EA ACCIDENT$EA ACCIDENT $DEDUCTIBLE$$$$EA PERSON$EA PERSON$EA ACCIDENT$EA ACCIDENT$EA PERSON$EA ACCIDENT$EA ACCIDENTDED$DED$$$$$$$TYPE OFCHANGEVEH #:$EA ACCIDENT$EA PERSON$EA ACCIDENT$EA ACCIDENT $DEDUCTIBLE$$$$EA PERSON$EA PERSON$EA ACCIDENT$EA ACCIDENT$EA PERSON$EA ACCIDENT$EA ACCIDENT$$$$$$$$INSURED SSIGNATUREDATE (MM/DD/YY)PRODUCER SSIGNATUREACORDTMDRIVER INFORMATIONACCIDENTS/CONVICTIONS - IF DRIVER ADDED (Note.)

3 Your driving record is verified with the state motor vehicle department)ADDITIONAL INTERESTADDITIONAL INTERESTREMARKSACORD 71 (1/97)ADDCHANGEDELETEADDCHANGEDELETETYPE OFCHANGE#NAMESEXDATEOF BIRTHOCCDATE LICACC PREVCSE DATEDRIVERS LICENSE #/LIC STATESOCIAL SECURITY #MARSTATREL TOAPPLICSTDT>100 GOODSTDTDRVTRAINHAS ANY DRIVER SHOWN ABOVE HAD AN ACCIDENT,REGARDLESS OF FAULT, OR BEEN CONVICTED OF A MOVING VIOLATION WITHIN THE LASTYEARS?DRV#DATE OFACCIDENT/CONVICTIONDESCRIPTION OF ACCIDENT OR CONVICTIONPLACE OFACCIDENT/CONVICTIONVEH #NAME AND ADDRESSLOAN NUMBERVEH #NAME AND ADDRESSLOAN NUMBERBI OR DEATHYESNOAMOUNT OFPROPERTY DAMAGEYESNOIF YES, INDICATE BELOW. ALSO INCLUDECOMPREHENSIVE INSURANCE INTLOSS PAYADDL INTLOSS PAY