Personal Auto

PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. THIS AUTHORIZATION SHALL EXPIRE ONE YEAR FROM THE DATE YOU SIGNED THE AUTHORIZATION.

APPLICANTS STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING. IN ADDITION, IF THE AUTO PLAN OR COMPANY DESIGNATED IN THIS APPLICATION IS NON-STANDARD, I CERTIFY THAT I UNDERSTAND THE RATES FOR THIS COVERAGE ARE HIGHER THAN NORMAL AND THEY ARE ACCEPTABLE TO ME AS I HAVE BEEN UNABLE TO OBTAIN COVERAGE DESIRED THROUGH THE NORMAL INSURANCE MARKET.

I UNDERSTAND AND ACKNOWLEDGE THAT UNINSURED MOTORISTS BODILY INJURY COVERAGE (UMBI) HAS BEEN OFFERED TO ME, AND THAT I HAVE THE OPTIONS OF SELECTING EITHER UMBI LIMITS LOWER THAN MY BODILY INJURY LIABILITY LIMITS, OR REJECTING UMBI COVERAGE ENTIRELY. IF I HAVE REJECTED UMBI COVERAGE OR SELECTED UMBI LIMITS LOWER THAN MY BODILY INJURY LIABILITY LIMITS, I HAVE ALSO SIGNED THE CALIFORNIA AUTO SUPPLEMENT, ACORD 61 CA. I ALSO UNDERSTAND AND ACKNOWLEDGE THAT UNINSURED MOTORISTS PROPERTY DAMAGE COVERAGE (UMPD) HAS BEEN OFFERED TO ME, AND THAT I HAVE THE OPTIONS OF SELECTING OR REJECTING THIS COVERAGE FOR ONE OR MORE VEHICLES. I HAVE MADE MY SELECTION ON THIS APPLICATION, AND I HAVE READ AND COMPLETED THE UMPD PORTION OF THE CALIFORNIA AUTO SUPPLEMENT, ACORD 61 CA. IN ADDITION, I HAVE BEEN OFFERED WAIVER OF COLLISION DEDUCTIBLE. IF THIS OPTION IS NOT INDICATED ON THIS APPLICATION, THEN I HAVE REJECTED THIS OPTION.

I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.