Automobile Insurance Acceptance Form.pub - Mea Financial Services printable pdf download

Automobile Insurance Acceptance Form

1216 Kendale Boulevard, P.O. Box 2501, East Lansing, MI 48826‐2501

Phone: 1‐800‐292‐1950 Fax: 517‐337‐5594 Web:

First Name

Middle Ini al

Last name

DOB

Marital Status:

Occupa on

(if re red, notate re red)

Spouse Name

Middle Ini al

Last Name

DOB

Marital Status:

Occupa on

(if re red, notate re red)

Street Address

City

Township

County

Zip Code

Home Phone Number

Business or Cell phone number

E‐mail address

Group Name (eg. MEA, MEA‐Reitred, AARP, Other

Group #

Previous Insurance Company Informa on

Name of Insurer

Policy #

Expira on Date

If previously insured under someone else’s policy, do not have a previous insurer or there is a lapse in coverage, please explain:

List all Household Members—

Include Members & Dependents who are temporarily living elsewhere (e.g. college)

Name of Household Member

Drivers License Number

Rela onship

Date of Birth

Male or Female

Occupa on

(If applicable)

Payment Informa on

A down payment is required (please refer to your quote for the exact amount). Payment may be made via a check/money order made payable to the company you are

accep ng the quote with or by ﬁlling in the EFT or debit/credit card informa on below. Please note that electronic payments will be taken as soon as the acceptance

form is received in our oﬃce.

Payment Method

Check is enclosed

EFT

Credit Card

Debit Card

Desired Payment Frequency

Full pay

Semi‐annual

Quarterly

Three Pay

Monthly

EFT Informa on (Complete only if you selected EFT for down payment or future payments)

Name of Financial Ins tu on

Checking

Savings

Banking Rou ng & Transit Number

Account Number

Signature

Date

Debit/Credit Card Informa on (Complete only if you selected Credit/Debit Card for down payment or future payments)

Card Number

Card Type:

Expira on Date

3‐dig security code

Visa

Mastercard

Other:

Signature

Date

No‐Fault Collision Insurance Authoriza on—

Oﬀer of collision coverage is made pursuant to Sec on 3037 of Public Act 145

Vehicle

Year

Make

Model

Vehicle ID number

Type of Collision

Deduc ble

(2014)

(Chevy)

(Impala)

(1X2243K222110DFK)

Limited

Regular

Broad

None

Limited

Regular

Broad

None

Limited

Regular

Broad

None

Limited

Regular

Broad

None

Acceptance

I declare the facts stated on all pages of this applica on to be true and request the Company to issue this insurance and any renewals thereof in reliance thereon.

I request this policy to be eﬀec ve at 12:01 a.m. standard me on: ________________________.

Date

Applicant’s Signature__________________________________________________________

Date____________________