AssuranceAmerica
Managing General Agency
PO Box 723128, AtlantaGA31139-0128 / POLICY NUMBERAGENT CODE
GA
/ AGENCY NAME TELEPHONEGeorgia Personal Car Application / SR22A FILING □ Yes □ No (Attach current MVR for all Drivers)
Term / / To / / Time AM/PM / PAYMENT OPTION □ Direct Bill ____Paid in Full
Applicant’s Name (Must be registered owner) SS #
______
Mail Address
______
______
HOME PHONE: ( )
Down Payment $ (checks payable to AssuranceAmerica)
Garage Location, if different from mail address:
Prior Insurance Carrier (Attach Proof) Policy Number
Termination Date Termination Reason / Employer Name Phone #
Address
COVERAGE (Indicate coverage requested by placing check mark X in box. Be sure to include limits and deductible selections where necessary)
Car / Bodily InjuryPropertyDamage / Medical Payments / UMAdded-On
UM Reduced / AD&D
$10/$1,000 / Comp & Collision / Spec Equip / LOU / Sub Total / Applicable Discounts
$ 25,000 / $ 50,000 BI
$25,000 PD / _____FULL _____LIMITED
$______/ $ ______
Deductible / $ ______/ Veh # Ded: / Attach list
And receipts / $ 20 a day / $400 per incident / □ Proof of Prior (1-30 days lapse)
□ Proof of Prior (0 days lapse)
□ Multi-Car
□ Homeowners □ Paid in Full
□ Safe Driver □ EFT
□ Good Student
1 / $ / $ / $ / $ / $ / $ / $ / $
2 / $ / $ / $ / $ / $ / $ / $ / $
3 / $ / $ / $ / $ / $ / $ / $ / $
Policy Fee $ Underwriting Fee $ SR22 Fee $ / Total Premium/ Fees / $
VEHICLE INFORMATION (In order of highest rated vehicles first)
Car / Year / Make & Model / Body type / Vehicle Identification Number / Symbol / Surcharge / 4WD
1
2
3
LEINHOLDER INFORMATION
Car / NAME / ADDRESS / CITY/STATE / ZIP1
2
3
DRIVER INFORMATION (Must list all persons age 14 and older, living in household OR having any regular vehicle use.)
Driver / Name / Sex / Marital Status / Relation to
Insured / Date of Birth
Mm/dd/yy / Driver’s License Number / State / # years
licensed / Occupation
1 /
Applicant
/Same
23
4
DRIVING RECORD (List ALL accidents and violation occurrences during the past 36 months)
Driver / mm/dd/yy / Detail of Accident or Infraction SR22A? Case # / Proof of No Fault? Proof must be attached / Points
APPLICANT’S QUESTIONNAIRE
1. Are all listed vehicles registered/titled in your name/resident spouse? Yes No If no, disqualified for coverage
2. Has any driver been licensed in Georgia less than 3 years? Yes No
If yes, most recently licensed in what state? Driver #1_____ #2_____ #3_____ #4_____
3. Are there other vehicles in the household not listed on the application? Yes No If Yes, list owner’s name/insurer in Remarks Section
4. Does any driver or operator have a Suspended or Revoked license? Yes No If Yes, please explain in Remarks Section
5. Are you or any other driver self-employed? Yes No If Yes, , please explain in Remarks Section
6. Is any insured vehicle used in any way in your business or occupation? Yes No If Yes, please explain in Remarks Section
• Do you or any other driver ever carry passengers to job sites? Yes No If Yes, please explain in Remarks Section
• Do you or any other driver ever carry occupational equipment or materials? Yes No If Yes, please explain in Remarks Section
7. Is any vehicle driven across state lines for business or school? Yes No If Yes, please explain in Remarks Section
8. Is auto driven over 50 miles one way to work or school? Yes No If Yes, please explain in Remarks Section
9. Do you, or any driver, have any physical or mental impairment? Yes No If Yes, please explain in Remarks Section
10. Is there any unrepaired damage of any kind to any car or truck listed? Yes No If yes, photos and Agent’s inspection must be attached
MEDICAL PAYMENTS COVERAGE
I understand no medical coverage is automatically afforded under this policy and I elect the following Medical Payments coverage and reject all other options.
Full coverage $1,000 $2,000 $ ______(Other limits submit unbound)
Limited coverage $1,000 $2,000 $ ______(Other limits submit unbound)
REJECTION of MEDICAL PAYMENTS COVERAGE
The Medical Payments coverage options have been fully explained to me and in consideration of a reduced premium, I fully understand that, with respect to the insurance afforded under Medical Payments, the definition of “reasonable medical expenses shall not include treatment, services, procedures or products that are chiropractic or delivered under the direction or supervision of a chiropractor. This endorsement also excludes treatment, services, procedures or products that are incurred for the use of thermography or acupuncture, or the purchase or rental of equipment not primarily designed to serve a medical purpose.
This additional option for Medical Payments coverage has been fully explained to me and I knowingly and willingly made the selection to accept this limitation to the Medical Payments coverage, as indicated by my signature below.
DO NOT SIGN TO ACCEPT LIMITED COVERAGE UNTIL YOU HAVE READ AND UNDERSTAND THE CONDITIONS NOTED ABOVE.
X Applicant’s Signature ______
UNINSURED MOTORIST COVERAGE
I elect the following Uninsured Motorists coverage subject to any applicable deductible for Property Damage by Georgia law. I understand that I have the right to purchase Uninsured Motorist coverage with limits not to exceed the liability limits of this policy. In accordance with the provision of the state law respecting Automobile Liability insurance which permits the insured named in the policy to reject or accept as indicated below, the Uninsured Motorists coverage, the undersigned insured does hereby, for the above policy and any renewal thereof, reject or accept as indicated below, such coverage provided the protection of persons insured under this policy who would legally be entitled to recover damages from the owner or operator of an uninsured motor vehicle because of bodily injury, sickness or disease, including death resulting therefrom, or property damage.
I ACCEPTADDED-ONUNINSURED MOTORIST COVERAGE
$25,000/$50,000/$25,000 limits $250_____deductible $500_____ deductible $1000______deductible
I REJECT ADDED-ON UNINSURED MOTORIST COVERAGE and I ACCEPT REDUCED UNINSURED MOTORIST COVERAGE
$25,000/$50,000/$25,000 limits $250_____deductible $500_____ deductible $1000______deductible
I REJECT UNINSURED MOTORIST COVERAGE IN ITS ENTIRETY
the additional options for uninsured motorist coverage have been fully explained to me. i understand my options for this coverage AND I MADE MY selection as reflected by my “X” in the appropriate box, above.
XApplicant’s Signature______
PUNITIVE DAMAGES EXCLUSION
I ACCEPT the Punitive Damages Exclusion at the reduced premium I do not want to exclude Punitive Damages
By accepting the Punitive Damages Exclusion, I understand that the Liability insurance provided by the policy will not apply to payment of any punitive or exemplary damages arising from any and all claims under the policy.
XApplicant's Signature______
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFICIARY
I select this coverage, as shown on the front of this application, and designate the following beneficiary:
Beneficiary’s name______Address______
REMARKS / EXPLANATION
______
APPLICANT’S STATEMENT
I hereby apply to the company for a policy of insurance. I understand that the information provided by me, as attested by my signature below, is material to the company’s agreement to issue a policy of automobile insurance, and that if information given herein is false, misleading or materially affects the conditions under which this policy shall become null and void. HAVING HAD ALL THESE OPTIONAL COVERAGES AND OPTIONAL LIMITS OFFERED AND EXPLAINED TO ME, I HEREBY SIGN FOR THE ACCEPTANCES OR REJECTIONS OF COVERAGE FOR THIS POLICY AND RENEWAL, REPLACEMENT, REINSTATEMENT, TRANSFER, OR SUBSTITUTE THEREOF AND FOR ANY ADDITIONAL OR SUBSTITUTION OF ANY MOTOR VEHICLE COVERED BY SUCH POLICY.
I understand that information regarding my driving record and the driving record of all individuals listed on this application will be secured by the insurance company. The company may also secure driving records on any individuals whose residence address is the same as yours, whether or not listed on this application and may use the information to determine eligibility for the insurance policy. The company may also secure accident or claim information from other insurance companies or insurance support organizations. This information may also be used to determine premium and/or eligibility for the insurance policy.
I agree that the insurance company has my permission to charge the correct rates and if the correct premium is not paid, I understand that the policy will be cancelled for non-payment of premium based on the correct premium developed. I further agree that if my down payment or full payment check is returned by the bank because of non-sufficient funds, coverage will be null and void from inception.
IMPORTANT: All coverages must indicate accepted or rejected and all appropriate boxes checked before being signed by applicant. If Uninsured Motorists Coverage rejection form is not fully completed and signed, the policy will be issued with Uninsured Motorist coverages included and the appropriate premium charged. Any other box for an optional coverage not checked indicates my rejection of the option.
I HEREBY ALLOW THE COMPANY TO RETAIN MY APPLICATION INCLUDING MY SIGNATURES UNDER FACSIMILE COPY AND/OR COMPUTER-SCANNED REPRODUCTION IN PLACE OF THE ORIGINAL FORM AND I WILL NOT DISPUTE THE USE OF SUCH REPLICATION AS ORIGINALS.
Date and TimeAMPMXApplicant’s signature ______
My agent has given me a copy of the Policy GA-1 (N: 01/16/06).X Applicant’s signature ______
AGENT’S STATEMENT
As a duly licensed agent of the state of Georgia, I hereby certify that to the best of my knowledge, all information contained herein is correct, the statements herein are those of the applicant who has signed this application in my presence, and that the applicant and the undersigned are retaining a duplicate signed copy hereof. I am legally qualified to submit this application on behalf of the applicant. I also certify that each of the coverages available on this policy, including Uninsured Motorist Coverage, Medical Payments Coverage, and their options, have been fully explained to the applicant.
I CERTIFY THAT I HAVE PERSONALLY INSPECTED ALL VEHICLES LISTED ON THIS APPLICATION.
Agent’s retained disclosure form: Date and time _____/____/______AM / PM Agent’s Signature______
I have given the insured a copy of the Policy GA-1 (N: 01/16/06). Agent’s Signature______
AAG01 0109