PERSONAL AUTO POLICY CHANGE REQUEST DATE …

1 E-MAILADDRESS:AGENCY CUSTOMER ID:CODE:SUBCODE:PHONE(A/C, No, Ext):CONTACTNAME:AGENCY(A/C, No):FAXTAX CODEINSURED'S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGEDINDICATE IF MAILING ADDRESS IS GARAGING ADDRESSNAMED INSURED(S) PERSONAL auto POLICY CHANGE REQUESTDATE (MM/DD/YYYY)DRV #REG TOVEHUSEDNEW/PURCHDATELEASEDDATEHP/CCYEA R*VINMAKEMODELBODY TYPEREGSTATEVEHICLE DESCRIPTION / USE*DRIVERGOVERNCODEGARPOOLCARCARMULTI-F ORMPER-USAGEMONTH# WKSWEEK# DAYSWK/SCHLMILE 1 WAYVEHDRIVER USE % (Each veh must equal 100%)ANNUALODOMETERTERRSYMBOLCOST NEWMILEAGEREADINGAGE GRPCOMP /OTC SYMCOLLSYMBRAKES 2/4 ANTI-LOCKVEHCREDITS ANDDEVICESAIRBAGPASSIVEDRV/BOTHSEAT BELTANTI-THEFTSURCHARGESCLASSBRAKES 2/4 ANTI-LOCKVEHCREDITS ANDDEVICESAIRBAGPASSIVEDRV/BOTHSEAT BELTANTI-THEFTSURCHARGESCLASSLOCCOMP / OTC$DEDUCTIBLEOPTION:$DEDUCTIBLEOPTION:C SL / BIPDUNINSUREDMOTORIST$EA PERSON$EA ACCIDENT$EA ACCIDENTOPTION:$EA PERSON$EA ACCIDENT$EA ACCIDENTOPTION:EA ACCIDENT$EA ACCIDENT$SINGLE LIMIT LIAB (CSL)COVERAGESVEH #:*VEH #:*$EA PERSON$EA ACCIDENT$EA PERSON$EA ACCIDENTBODILY INJURY LIABPROPERTY DAMAGE LIAB$EA ACCIDENT$DEDUCTIBLE$EA ACCIDENT$DEDUCTIBLEEA PERSON$EA PERSON$MEDICAL PAYMENTSACV UNLESS AMT STATED$LIMIT$LIMITCSL / BIPDUNDERINSUREDMOTORIST$EA PERSON$EA ACCIDENT$EA ACCIDENTOPTION:$EA PERSON$EA ACCIDENT$EA ACCIDENTOPTION:$DEDUCTIBLEOPTION:$DEDUCT IBLEOPTION:COLLISION$$TOWING & LABORLIMITLIMIT$EA DAYMAXIMUM$$EA DAYMAXIMUM$TRANS EXP / RENTAL REVEHICLE COVERAGES (excluding NO FAULT) 1997-2012 ACORD CORPORATION.

2 All rights 71 (2012/03)The ACORD name and logo are registered marks of ACORDATTENTIONAGENCYDIRECTCHANGE BILLING PLAN TO:COLUMNS INDICATED WITH AN ASTERISK * ARE INTENDED FOR"TYPES OF CHANGE " CODES. PERMISSIBLE "TYPE OF CHANGE "CODES ARE:C - CHANGEEFFECTIVE date OF CHANGEEFFECTIVE date OF POLICYEXPIRATION DATEACCOUNT NUMBERNAIC CODECARRIERPOLICY NUMBERA - ADDD - DELETEI - INFORMATION ONLY (NO CHANGE )Page 1 of 3 LOCGARAGING ADDRESS(ES)STREETCITYCOUNTYSTATEZIP + 4*REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)AGENCY CUSTOMER ID:DRIVER INFORMATIONSEX#* date OF BIRTHNAME (AS IT APPEARS ON LICENSE)FIRST NAMEMIDDLE NAMELAST NAMEMARSTATREL TOAPPLIC*OCCUPATION#TRAINDRVSTDTGOOD>100 STDTSOCIAL SECURITY #DRIVERS LICENSE #CSE DATEACC PREVDATE LICLICSTATE* MARITAL STATUS / CIVIL UNION (if applicable)ADDITIONAL VEHICLE COVERAGES (including NO FAULT)CODEDESCRIPTIONLIMITLIMIT APPLIES TODEDUCTIBLEOPTIONS*VEH$$$%$$$%$$$%$$$%$ $$%$$$%$$$%$$$%$$$%$$$%$$$%$$$%PROPERTY DAMAGEACCIDENT / CONVICTIONDESCRIPTION OF ACCIDENT OR CONVICTIONACCIDENT / CONVICTION#DRVDATE OFPLACE OFBI OR DEATHAMOUNT OFY / NHAS ANY DRIVER SHOWN ABOVE HAD AN ACCIDENT, REGARDLESS OFFAULT, OR BEEN CONVICTED OF A MOVING VIOLATION WITHIN THE LASTYEARS?

3 Y / NIF YES, INDICATE BELOW. ALSO INCLUDE COMPREHENSIVE INSURANCE / CONVICTIONS- IF DRIVER ADDED (Note: Your driving record is verified with the state motor vehicle department & other insurers)Y / NIF A VEHICLE IS BEING ADDED, ANSWER QUESTIONS 1- 3 and 9. IF A DRIVER IS BEING ADDED, ANSWER QUESTIONS 4- 9 GENERAL INFORMATION (Explain all "YES" responses)2. ANY CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans/pickups)DESCRIPTIONCOST$DESCRIPTION COST$VEH #VEH #3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass)DESCRIPTIONDESCRIPTIONVEH #VEH #ANY HOUSEHOLD MEMBER IN MILITARY SERVICE? #BRANCHRANKBASE LOCATIONVEH AT BASE (Y / N)ANY DRIVERS LICENSE BEEN SUSPENDED / REVOKED? #SUSPENSION PERIODS tart date :End THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY ANDREGISTERED TO THE APPLICANT?

4 VEH #NAME OF OTHER OWNERVEH #NAME OF OTHER OWNERPage 2 of 3 ACORD 71 (2012/03)Page 3 of 3 AGENCY CUSTOMER ID:Y / NIF A VEHICLE IS BEING ADDED, ANSWER QUESTIONS 1- 3 and 9. IF A DRIVER IS BEING ADDED, ANSWER QUESTIONS 4- 9 GENERAL INFORMATION (continued) (Explain all "YES" responses) FINANCIAL RESPONSIBILITY FILING?DRV #REASON FOR FILINGFILING DATEANY COVERAGE DECLINED, CANCELLED, OR NON-RENEWED DURING THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question) #REASON DECLINED, CANCELLED, OR DRIVER UNDERGOING A COURSE OF MEDICAL TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT? (Not applicable in MT, OR and WI)DRV # DRIVER HAVE A PHYSICAL IMPAIRMENT? (Not applicable in MT and WI)DRV #DESCRIPTION OF SPECIAL EQUIPMENT IN VEHICLEADDITIONAL INTERESTREGISTRANTLIENHOLDEROWNERLOSS PAYEEADDITIONAL INSUREDNAME AND ADDRESSINTERESTVEHICLE:INTEREST IN ITEM NUMBERRANK:REFERENCE / LOAN #:LOCATION:ADDCHANGEDELETEADDITIONAL INTERESTADDCHANGEDELETEANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES.

5 (Notapplicable 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)IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES ASTATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTYOF A FELONY OF THE THIRD MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUDANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIMCONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATIONCONCERNING ANY FACT MATERIAL THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIMEAND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE.

6 OR MISLEADING INFORMATION TO ANINSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, ANDDENIAL OF INSURANCE THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURERFOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/ORFINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF FALSE INFORMATION MATERIALLY RELATED TO ACLAIM WAS PROVIDED BY THE KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED ORPREPARES 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 THEISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FORPAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICHSUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO.

7 ORCONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS AFRAUDULENT INSURANCE PRODUCER LICENSE NOPRODUCER'S NAME (Please Print)INSURED'S SIGNATUREDATEPRODUCER'S SIGNATURE(Required in Florida)NATIONAL PRODUCER NUMBERSIGNATUREREGISTRANTLIENHOLDEROWNER LOSS PAYEEADDITIONAL INSUREDNAME AND ADDRESSINTERESTVEHICLE:INTEREST IN ITEM NUMBERRANK:REFERENCE / LOAN #:LOCATION:ACORD 71 (2012/03)