Automobile Insurance Acceptance Form.pub - Mea Financial Services (Page 2 of 2) in pdf

Credit Union, Finance or Lease Company Informa on

Vehicle

Lease

Lien

Complete Name, Mailing address and Zip Code of Company

Underwri ng Ques ons

1. Does any driver require ﬁnancial responsibility ﬁling?

Yes

2. Have you had auto insurance cancelled, declined, renewal refused or been in an assigned risk plan?

Yes

3. Has any driver had a license suspension or revoca on in the past 5 years?

Yes

4. Are there any other driver(s) that are not listed?

Yes

5. Is there any exis ng damage or is/are vehicle(s) in unsafe driving condi on?

Yes

6. Provide name and reason for anyone else tled on the auto(s) other than spouse or lienholder:

Name _________________________________ Reason________________________________________________

7. Is any vehicle listed used in a business for transporta on of merchandise or passenger for hire?

Yes

8. Has any vehicle been altered, modiﬁed, or converted in any way?

Yes

9. Has any household member been convicted of fraud or denied coverage because of intent to commit fraud?

Yes

10. Are any of the vehicles to be insured parked somewhere other than the applicant’s address?

Yes

If not, provide address of where kept & why ________________________________________________________

11. List children’s names and dates of birth who do not drive:

Name____________________ DOB___________________

Yes

12. Do you desire coordina on of beneﬁts for wage loss?

(You are only eligible for this if you and your spouse have disability insurance)

13. Does your health Care plan provider exclude injury as a result of automobile related accidents?

Yes

Please provide explana ons to “yes” answers above where space was not provided or addi onal space is needed.

Applicant Statements

The following collision coverage op ons are available:

Limited Collision Coverage ‐ The company will pay for collision damage when the driver of the insured vehicle is not more than 50% of the cause of the accident. If the driver of the insured vehicle is

more than 50% of the cause of the accident, the company will not pay for collision damage. If you have chosen a deduc ble, you must pay the deduc ble amount.

Regular Collision Coverage ‐ The company will pay for collision damage to the insured vehicle, regardless of who is responsible for the accident. You must pay the deduc ble amount.

Broad Form Collision Coverage‐ The company will pay for collision damage to the insured vehicle, regardless of who is responsible for the accident. However, if the driver of the insured vehicle was

more than 50% of the cause of the accident, you must pay the deduc ble amount.

No Collision ‐ The company will not pay for collision damage to the insured vehicle.

I choose to purchase the type(s) of collision coverage(s) and deduc ble(s) as indicated in the "No‐Fault Collision Insurance Authoriza on” sec on of this applica on. I understand that if I have

checked "No Collision", I hereby reject any Collision coverage on such vehicle. Future renewals shall comply with these instruc ons unless I indicate otherwise in wri ng to the Company.

Note: For accidents on or a er July 1, 1980, you may sue the driver of another vehicle who was 50% or more of the cause of the accident to recover your uninsured damage, up to a maximum of

$1,000. You must bring this ac on in the Small Claims Division of the District Court or Municipal Court. Any award to you may be reduced by the percentage of which you were the cause of the

accident. The Company is not responsible for ﬁling the suit on your behalf, and the other driver's insurance company may not be responsible to pay any award to you on behalf of the other driver.

I choose to purchase the type(s) of collision coverages and deduc bles as indicated and hereby reject the other collision coverage op ons oﬀered. I understand

that for any vehicle I have

checked “no coverage,” I hereby reject any collision coverage on such vehicle. I authorize future renewals in compliance with these instruc ons un l such me as I indicate otherwise in wri ng to

the company.

Applicant’s Signature

_____________________________________________________________________

Date_______________________

No ce: Any person who, with intent to defraud or knowing that he is facilita ng a fraud against an insurer, submits an applica on or ﬁles a claim containing a false or decep ve statement is guilty of

insurance fraud.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: In making this applica on for insurance, it is understood that as part of our underwri ng procedure, we may develop infor‐

ma on using one or more of the following: physical inspec ons of the vehicle(s), consumer reports, motor vehicle records and independently maintained records of previously ﬁled claims. You will

be no ﬁed whenever informa on from a consumer repor ng agency results in an adverse ac on.

In connec on with this applica on for insurance, we may review your credit report or obtain or use a credit based insurance score based on the informa on contained in that credit report. We may

use a third party in connec on with the development of your Insurance Score. Extraordinary life circumstances occur, which may adversely aﬀect your Insurance Score. If you believe such an event

has occurred in your life, you may request an exemp on to our use of your Insurance Score, which, if accepted, will result in your policy being placed in our Neutral Insurance Score er.

The facts stated on this applica on are true to the best of my knowledge and are to be relied upon by the Company for the purpose of issuing the insurance that I have requested, and any renewals

of this insurance. I understand that if I am not eligible for a speciﬁc Company, program, or ra ng er for which I have applied, my policy may be issued or renewed in a diﬀerent program or ra ng

er. I have discussed my speciﬁc insurance needs with my agent in order to determine the most appropriate policy for my situa on.