Application for Antique & Classic Auto Insurance * Required Fields Applicant* Date of Birth* Occupation* Street* Phone Number* E-mail* City* County* State* Zip* List all Licensed Drivers in household: SL.NO DRIVERS NAME State & Driver's LICENSE NUMBER DATE OF BIRTH NUMBER OF YRS. LICENSED YEAR & MAKE OF VEHICLE DRIVEN FOR DAILY USE Co. 1.) 2.) 3.) Attach a separate sheet for additional drivers. If company vehicle, check ( ) The following coverages are available. Indicate your selections by placing an "X" in the proper box. All Rates are Annual Rates.   $ Total   Liability Coverage- $85,000 Single Limit Bodily Injury & Property Damage - I" Vehicle $10.00, 2nd $6.00, 3'" $4.00 Additional vehicles-no charge. $    Liability Coverage- $100,000 Single Limit Bodily Injury & Property Damage - 1" Vehicle $15.00, 2nd $10,00,3'" $5.00 Additional vehicles-no charge. $    Liability Coverage- $300,000 Single Limit Bodily Injury & Property Damage - 1" Vehicle $20.00, 2""$14.00, 3"' $8.00 Additional vehicles-no charge. $    Liability Coverage - Other limits available. Please contact customer service for limits and rates $    Medical Payments - $500 Limit - I" Vehicle $1.00, 2nd $1.00, 3'" $1.00. Additional vehicles - no charge. $    *Personal Injury Protection (pIP) - Basic, I" Vehicle $4.00, 2nd $3.00,3'" $2.00 Additional vehicles-no charge. See table on back for additional limits and rates. $    *UninsuredlUnderinsured Motorists - $85,000 Single Limit Bodily Injury & Property Damage - I" Vehicle $6.00, 2nd $6.00, 3'" $6.00. Add'l veh. - no charge. $    *UninsuredlUnderinsured Motorists (increased limits) - see the table on back for limits and rates and enter the additional premium: 1st Vehicle  2st Vehicle  3st Vehicle  Additional vehicles - no charge. $     Physical Damage - Other than Collision (Comprehensive) Coverage - $0.35/hundred for Antique Vehicles 25 years or older No Deductible - $O.60/hundred for Collectible Vehicles (15-24 years old) $     Physical Damage - Collision Coverage - - $0.35/hundred for Antique Vehicles 25 years or older No Deductible - $O.60/hundred for Collectible Vehicles (15-24 years old) $  Note: Collision Coverage is only available with Other than Collision (Comprehensive) Coverage   Towing & Roadside Assistance - $12.00 per Policy (Only available with Collision Coverage) $  Total Annual Premium $  Requested effective date of coverage        Minimum Policy Premium is $75.00 ANTIQUE VEHICLES TO BE INSURED** We require: 1) Recent color Photo of each vehicle listed, & 2) Payment in full at the time of submission of this application SL.NO YEAR MAKE BODY TYPE SERIES OR MODEL VEHICLE IDENTIFICATION SERIAL OR MOTOR NUMBER VALUE IS THE VEHICLE REGISTERED? (Select one) STATE OF REISTRATION 1.) Yes NO 2.) Yes NO 3.) Yes NO Use separate sheet for additional vehicles to be insured These vehicle(s) will be used mainly in exhibition cub activities, parades and other functions of public interest and will not be used primarily for the transportation of passengers or goods. Important! See other side for additional questions and required signature. Broker / Produc,er Information (if applicable) Producer Name    Address    City       State       Zip   Phone      Fax   E-mail      I.D.#   PRODUCER CANNOT BIND COVERAGE. NO COVERAGE IS PROVIDED UNTIL OR THE INSURER BINDS COVERAGE. TO properly expedite the handling of your application, please answer the following questions. Explain in details for theneccessary questions. 1. Have you or any driver in your household had any auto losses or moving violations in the past 3 years? If Yes, explain sInclude: Date-Cause-Payment. Yes NO 2. Will you be using your antique/classic vehicle as a means of daily transportation, errands, or back-up? Yes NO 3. Do you belong [0 an automobile club? If yes, whieh elub?    Yes NO 4. Has (will) the body, engine, or drive train of the antique/classic vehicle been(be) changed?    If yes. explain   Yes NO 5. Has the manufacturer's horsepower for your vehicle been changed? If yes, explain    Yes NO 6. Is any vehicle currently under restoration? If yes, a.) What is the expected date of completion?    b.] Ifin shop, list name and address    Yes NO 7. Are all antique/classic vehicle(s) garaged? Yes NO 8. Construction of garage:    Cinder Block    Wood Frame     Other (explain)   Location(s) of garage(s) a.) Same as mailing address?  Yes NO If No, list full garage address 9. Construction of garage: What is the annual mileage? (a) Club functions miles   (b) Other purposes miles  (b) Explain  Fraud Statement IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,!"IN~S, DEN~ ()F INSUI0NCE,.!\ND CIVIL I?AMAGES. I agree that the insurer may investigate and secure consumer reports, including motor vehicle reports for persons listed in the application. I the insurer may investigate and secure new consumer reports in evaluating this policy for each future renewal or replacement policy. I declare that the information contained in this application is tr information in determining my eligibility and premium. I declare that the selections indicated in this application accurately reflect the limits, coverages and deductibles I chose. I understand my producer is submitting this application to an appointed agency of an insurer, and that my producer does not have binding authority with the insurer. Iunderstand Iwill not have coverage until Iam informed by the appointed agency or the insurer that coverage is bound or issued. I agree that the Company and its affiliates may use any telephone number I provide now or in the future to contact me by way oflive calls or by use of any automatic dialing system or artificial or prerecorded voice. My vehicie(s) will be used mainly in exhibitions, club activities, parades and other functions of public interest and will not be used primarily for the transportation of passengers or goods. There is no coverage until specific notification SIGNATURE OF APPLICANT(S)  DATE  Medical Payments Personal Injury Protection (PHP) Increased Limits 1" Vehicle 2"d Vehicle 3rd Vehicle Add'l Veh. Benefits - Max Limit Is' Vehicle 2"d Vehicle 3rd Vehicle Add'l Veh.   $1,000 $2.00 $2.00 $2.00 No Charge   $2,500 Basic Premium included on front of application.   $2,500 $3.00 $3.00 $3.00 No Charge   $5,000 $11.00 $10.0 $9.00 No Charge   $5,000 $4.00 $4.00 $4.00 No Charge   $10,000 $19.00 $18.00 $17.00 No Charge   $10,000 $6.00 $6.00 $6.00 No Charge Uninsured/Underfnsured Motorists (UM/UIM)-Bodily Injury Property Damage Increased Limits Add to Basic UM/UIM Premium on front of application   1stVehicle 2"d Vehicle 3rd Vehicle Additional Veh.  $100,000 Single Limit $4.00 $4.00 $4.00 No Charge  $300 000 Sin le Limit $6.00 $6.00 $6.00 No Charge To reject UM/UIM or PIP coverages, please use state Se1ectionlRejection Form. Higher limits of $500,000 and $1 million available upon request and with further underwriting review and copy of daily car policy. Please contact customer service for rates. APPOINTED AGENCY  APPOINTED AGENCY CODE  Underwritten by Foremost Insurance Company Grand Rapids, Michigan To effect insurance, we require payment of entire premium, Completed forms, Photos, complaince with state regulations and acceptance of risk. There in no coverage until the producer or applicant is notified by Jess Akin Insurance. Check List Signes, Fully completed application Check for full premium Signed state Selection/Rejection forms (if applicable) Apprasial required when insured value falls outside of standard hooby valution guides Recent, color photo of each vechile, photos may be e-mailed to jakin@jessakin.com Date Photos E-mailed: Please type the code shown*      Copyright © 2007 [Directory One, Inc.]. All rights reserved Site designed by "Innovative Tech Services Inc."