Insurance Contact Form

Applicant:

Home Phone:

Work Phone:

Address:

City:

State:

Zip Code:

Garaging Address:

Occupation/Employer Name:

Employer Address:

If "Yes" to the folowing questions, in box below give details. Y N

1) Any existing damage to your vehicle(s)?

2) Does applicant or any driver have a mental
or physical impairment? If Yes, SUBMIT PHYSICIAN'S STATEMENT

3) Is vehicle used for any type of delivery or
used at various job sites during the day?

4) Do you and all regular drivers listed below live away from
above residence more then 2 months a year?

Explanation of Questions 1 through 4:

Applicant warrants there are no other residents of insured's household(aged 15 and older) and no regular drivers other than those listed below. If additional room is needed, please use the back of the application.

Name Sex Date of Birth Married License # State Relation

Occupation #2:

Employer's Name:

Occupation #3:

Employer's Name:

Veh. Year Make, Model & Style VIN

Veh. Lienholder Add'l Int. Name & Address of Lienholder or Additional Interest

SR-22 Required? Yes No

Driver #

For each driver list and Describe All Accidents, Moving Violations and Suspensions in past 3 Years below Driver #

VEHICLE(S) MUST BE REGISTERED TO APPLICANT

Business Use
Vehicle #1 Y N
Vehicle #2 Y N
Vehicle #3 Y N

REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE
I have applied for bodily injury coverage in limits higher than basic statutory limits. I understand that I may purchase uninsured/underinsured motorist coverage up to the bodily injury limit. I REJECT ADDITIONAL UNINSURED/UNDERINSURED MOTORIST COVERAGE.

YES NO *Required

The applicant acknowledges, having been advised of uninsured motorist property damage coverage, the premium therefor, and a brief description of the coverage.

YES NO *Required

I certify that all persons age 15 or over who live with me or operate my vehicle(s) have been reported to the Company, and I will inform the Company of future additions.

YES NO *Required

NOTICE AS REQUIRED UNDER THE FAIR CREDIT REPORTING ACT(S)
This is to inform you that as part of our procedure for processing your insurance application an investigative consumer report may be requested for the preparation of a report whereby information is obtained through personal interviews with your neighbors, friends or others with whom you are acquainted or who may have knowledge of any such items of information. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living. You have the right to make a written request to be informed as to whether or not such consumer report was requested, and if such report was requested, the name and address of the consumer reporting agency to whom the request was made. You may receive a copy of this report by contacting such agency.
APPLICANT STATEMENT:
The applicant hereto, states that he/she has read this application and warrants that the information provided by the applicant is true and complete and without omission and that said information was provided as an inducement to the insurance company to issue a policy, and it is a special condition of this policy that it shall be NULL and VOID and of no benefit or effect whatsoever as to any claim arising there under in the event that the information in the application should provide to be false or fraudulent in nature. It is understood that NO COVERAGE will be effective if the check given as down payment is not honored by the bank upon which it is drawn.

YES NO *Required

CREDIT CARD TRANSACTION INFORMATION

Visa, Mastercard, Discover and AMEX Only

Insured Name:

Credit Card Number:

V Code:

Cardholder's Name:

Cardholder's Street:

Cardholder's City:

Cardholder's State:

Cardholder's Zip Code:

Amount of Charge:

FILL IN ABOVE THE AMOUNT INDICATED TO YOU BY SALES REPRESENTATIVE

Expiration Date:

Daytime Phone:

Cardholder name, card number, expiration date and V code must match card exactly! No transactions will be accepted unless all the above information is obtained. The completion of this form and the proceeding application in no way binds or issues insurance on the above named insured. A LEDBETTER INSURANCE sales representative will call you promptly when coverage has been placed.

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