PERSONAL AUTO POLICY CHANGE REQUEST DATE …

1 REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)*ZIP + 4 STATECOUNTYCITYSTREETGARAGING ADDRESS(ES)LOCPage 1 of 3I - INFORMATION ONLY (NO CHANGE )D - DELETEA - ADDPOLICY NUMBERCARRIERNAIC CODEACCOUNT NUMBEREXPIRATION DATEEFFECTIVE date OF POLICYEFFECTIVE date OF CHANGEC - CHANGECOLUMNS INDICATED WITH AN ASTERISK * ARE INTENDED FOR "TYPES OF CHANGE " CODES. PERMISSIBLE "TYPE OF CHANGE " CODES ARE: CHANGE BILLING PLAN TO:DIRECTAGENCYATTENTIONThe ACORD name and logo are registered marks of ACORDACORD 71 (2012/03) 1997-2012 ACORD CORPORATION. All rights COVERAGES (excluding NO FAULT)TRANS EXP / RENTAL RE$MAXIMUMEA DAY$$MAXIMUMEA DAY$LIMITLIMITTOWING & LABOR$$COLLISIONOPTION:DEDUCTIBLE$OPTION :DEDUCTIBLE$OPTION:EA ACCIDENT$EA ACCIDENT$EA PERSON$OPTION:EA ACCIDENT$EA ACCIDENT$EA PERSON$UNDERINSURED MOTORISTPDCSL / BILIMIT$LIMIT$ACV UNLESS AMT STATEDMEDICAL PAYMENTS$EA PERSON$EA PERSONDEDUCTIBLE$EA ACCIDENT$DEDUCTIBLE$EA ACCIDENT$PROPERTY DAMAGE LIABBODILY INJURY LIABEA ACCIDENT$EA PERSON$EA ACCIDENT$EA PERSON$*VEH #:*VEH #:COVERAGESSINGLE LIMIT LIAB (CSL)$EA ACCIDENT$EA ACCIDENTOPTION:EA ACCIDENT$EA ACCIDENT$EA PERSON$OPTION:EA ACCIDENT$EA ACCIDENT$EA PERSON$UNINSURED MOTORISTPDCSL / BIOPTION:DEDUCTIBLE$OPTION.

2 DEDUCTIBLE$COMP / OTCLOCCLASSSURCHARGESANTI-THEFTSEAT BELTDRV/BOTHPASSIVEAIRBAGDEVICESCREDITS ANDVEHANTI-LOCKBRAKES 2/4 CLASSSURCHARGESANTI-THEFTSEAT BELTDRV/BOTHPASSIVEAIRBAGDEVICESCREDITS ANDVEHANTI-LOCKBRAKES 2/4 SYMCOLLOTC SYMCOMP /AGE GRPREADINGMILEAGECOST NEWSYMBOLTERRODOMETERANNUALDRIVER USE % (Each veh must equal 100%)VEHMILE 1 WAYWK/SCHL# DAYSWEEK# WKSMONTHUSAGEPER-FORMMULTI-CARCARPOOLGAR CODEGOVERNDRIVER*VEHICLE DESCRIPTION / USESTATEREGBODY TYPEMODELMAKEVIN*YEARHP/CCDATELEASEDDATE PURCHNEW/USEDVEHREG TODRV # date (MM/DD/YYYY) PERSONAL auto POLICY CHANGE REQUESTNAMED INSURED(S)INDICATE IF MAILING ADDRESS IS GARAGING ADDRESSINSURED'S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGEDTAX CODEFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILACORD 71 (2012/03)Page 2 of 3 NAME OF OTHER OWNERVEH #NAME OF OTHER OWNERVEH #WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT?

3 date :Start date :SUSPENSION PERIODDRV # DRIVERS LICENSE BEEN SUSPENDED / REVOKED?VEH AT BASE (Y / N)BASE LOCATIONRANKBRANCHDRV # HOUSEHOLD MEMBER IN MILITARY SERVICE?VEH #VEH #DESCRIPTIONDESCRIPTION3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass)VEH #VEH #$COSTDESCRIPTION$COSTDESCRIPTION2. ANY CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans/pickups)GENERAL INFORMATION (Explain all "YES" responses)IF A VEHICLE IS BEING ADDED, ANSWER QUESTIONS 1- 3 and 9. IF A DRIVER IS BEING ADDED, ANSWER QUESTIONS 4- 9Y / NACCIDENTS / CONVICTIONS- IF DRIVER ADDED (Note: Your driving record is verified with the state motor vehicle department & other insurers)IF YES, INDICATE BELOW. ALSO INCLUDE COMPREHENSIVE INSURANCE / NYEARS?FAULT, OR BEEN CONVICTED OF A MOVING VIOLATION WITHIN THE LASTHAS ANY DRIVER SHOWN ABOVE HAD AN ACCIDENT, REGARDLESS OFY / NAMOUNT OFBI OR DEATHPLACE OFDATE OFDRV#ACCIDENT / CONVICTIONDESCRIPTION OF ACCIDENT OR CONVICTIONACCIDENT / CONVICTIONPROPERTY DAMAGE%$$$%$$$%$$$%$$$%$$$%$$$%$$$%$$$%$ $$%$$$%$$$%$$$VEH*OPTIONSDEDUCTIBLELIMIT APPLIES TOLIMITDESCRIPTIONCODEADDITIONAL VEHICLE COVERAGES (including NO FAULT)* MARITAL STATUS / CIVIL UNION (if applicable)STATELICDATE LICACC PREVCSE DATEDRIVERS LICENSE #SOCIAL SECURITY #STDT>100 GOODSTDTDRVTRAIN#OCCUPATION*REL TO APPLICMAR STATLAST NAMEMIDDLE NAMEFIRST NAMENAME (AS IT APPEARS ON LICENSE) date OF BIRTH*#SEXDRIVER INFORMATIONAGENCY CUSTOMER ID:ACORD 71 (2012/03)LOCATION:REFERENCE / LOAN #:RANK:INTEREST IN ITEM NUMBERVEHICLE.

4 INTERESTNAME AND ADDRESSADDITIONAL INSUREDLOSS PAYEEOWNERLIENHOLDERREGISTRANTSIGNATUREN ATIONAL PRODUCER NUMBER(Required in Florida)PRODUCER'S SIGNATUREDATEINSURED'S SIGNATUREPRODUCER'S NAME (Please Print)STATE PRODUCER LICENSE NOIN KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON.

5 PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE.

6 OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)DELETECHANGEADDADDITIONAL INTERESTDELETECHANGEADDLOCATION:REFERENC E / LOAN #:RANK:INTEREST IN ITEM NUMBERVEHICLE:INTERESTNAME AND ADDRESSADDITIONAL INSUREDLOSS PAYEEOWNERLIENHOLDERREGISTRANTADDITIONAL INTERESTDESCRIPTION OF SPECIAL EQUIPMENT IN VEHICLEDRV #ANY DRIVER HAVE A PHYSICAL IMPAIRMENT? (Not applicable in MT and WI) #ANY DRIVER UNDERGOING A COURSE OF MEDICAL TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT?

7 (Not applicable in MT, OR and WI) DECLINED, CANCELLED, OR NON-RENEWEDDRV # COVERAGE DECLINED, CANCELLED, OR NON-RENEWED DURING THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)FILING DATEREASON FOR FILINGDRV #ANY FINANCIAL RESPONSIBILITY FILING?8. GENERAL INFORMATION (continued) (Explain all "YES" responses)IF A VEHICLE IS BEING ADDED, ANSWER QUESTIONS 1- 3 and 9. IF A DRIVER IS BEING ADDED, ANSWER QUESTIONS 4- 9Y / NAGENCY CUSTOMER ID:Page 3 of 3