MASSACHUSETTS RIDERS CHOICE PROGRAM APPLICATION

Transcription

1 U N I T 4 U N I T 3 U N I T 2 U N I T 1 AMERICAN MODERN HOME INSURANCE COMPANY MASSACHUSETTS RIDERS CHOICE PROGRAM APPLICATION Policy # 077 Agency Code # Agency Name Address City, State & Zip Phone Number ( ) Previous AMIG Policy # Subproducer # Sub Name Address City, State & Zip Phone Number ( ) BASIC / CLIENT INFORMATION Titled Owner / First Name Middle Initial Titled Owner / Last Name Home Phone ( ) Work Phone ( ) Mailing Address (Street) City State Zip Effective Date Is mailing address the Total # of Operators Total # of Units same as Unit 1 address? (Including Excluded Operators) Term Yes No 12 Month ADDITIONAL INSURED INFORMATION (IF N/A, DO NOT COMPLETE) First Name Last Name Mailing Address (Street) City Birthday State Zip (MM/DD/YYYY) Social Security Number Occupation Additional Insured Type Joint Owner Lienholder Other OPERATOR INFORMATION (ALL INFORMATION REQUIRED) OP Marital Gender Birthdate Driver's License Current # First Name Last Name Social Security Number Status (M/F) (MMDDYY) License # State MVR (Y/N) Occupation OP Year Began Driving Valid Cycle SR-22 Excluded Operator Cycle Driver Training # Primary Residence Street Driven Units License (Y/N) (Y/N) (Y/N) (MM/DD/YYYY) 1 Own Rent Live w/ Parent Other 2 Own Rent Live w/ Parent Other 3 Own Rent Live w/ Parent Other 4 Own Rent Live w/ Parent Other 5 Own Rent Live w/ Parent Other ACCIDENT / VIOLATION INFORMATION List all traffic law violations, accidents (regardless of fault) and any insurance losses for all operators in the last 3 years (start with the most recent). Operator Incident Date Loss Operator Incident Date Loss # Accident or Violation Type (MM/DD/YYYY) Amount # Accident or Violation Type (MM/DD/YYYY) Amount UNIT INFORMATION MC-AP-MA (10/12)

2 U N I T 1 U N I T 2 U N I T 3 U N I T 4 Coverage Eligibility Questions UNIT 1 UNIT 2 UNIT 3 UNIT 4 Yes No Yes No Yes No Yes No 1. Garaged in city limits? 2. Is unit re-titled WITH a State Assigned VIN? 3. Is unit street driven? 4. Total limit of accessories, sidecars and/or Trailers? Underwriting Questions (ANY YES ANSWER DEEMS THE ENTIRE RISK INELIGIBLE.) Yes No 1. Any unit salvaged or non-factory built WITHOUT a State Assigned VIN? 2. Any unit titled in the name of a corporation? or business? 3. Any unit classified as a home-made kit motorcycle? 4. Does any unit have titled owners that reside in separate households? 5. Any unit designed/used for racing? Indicate current or previous carrier. Carrier Name: CURRENT / PREVIOUS INSURANCE Carrier Name: Carrier Name: COVERAGE SUMMARY UNIT 1 UNIT 2 UNIT 3 UNIT 4 Class/Sub-class Coverage Selection (see guidelines for coverage Limit/ Limit/ Limit/ Limit/ eligibility and requirements) Deductible Premium Deductible Premium Deductible Premium Deductible Premium Mandatory Coverages (limits must match for all units) Carrier Name: Bodily Injury (20/40; 25/50; 50/100; 100/300; 250/500) Property Damage (5,000; 10,000; 25,000; 50,000; 100,000) Optional Coverages Personal Injury Protection (1,000 Deductible) Yes No Yes No Yes No Yes No Comprehensive (100; 250; 500; 1,000 Deductible) Collision (100; 250; 500; 1,000 Deductible) Accessories Safety Apparel (1,000 Included with Collision Coverage) Discounts/Surcharges Applied Yes No Yes No Yes No Yes No Homeowner Discount Yes No Yes No Yes No Yes No Transfer Discount 1 Yes No Yes No Yes No Yes No Transfer Discount 2 Yes No Yes No Yes No Yes No Multi-Unit Discount Yes No Yes No Yes No Yes No Driving Record Surcharge Yes No Yes No Yes No Yes No Unverifiable MVR Surcharge Yes No Yes No Yes No Yes No Ineligible Risk Surcharge Yes No Yes No Yes No Yes No Total Unit Premium (reflects discounts and/or surcharges) Total Policy Premium (reflects discounts and/or surcharges) BILLING INFORMATION When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. Policy Term Payment Plan Minimum Down Payment Down Payment Method Payment Received EFT Bank ABA# EFT Account Number EFT Account Type Eff. Day of Month(1-28) Credit Card Type Credit Card Number Expiration Date(MMDDYYYY) AGENT REMARKS APPLICANT'S STATEMENT I affirm that the information provided is true and to the best of my knowledge and that no material information has been withheld. I also confirm that the Coverages and Limits described above are the Coverages and Limits I desire. I hereby authorize appropriate state authorities to release my motor vehicle driving record to American Modern Home Insurance Company or its representative. This release shall remain in effect until I request in writing that it be withdrawn. I understand that as part of routine procedures, a consumer report may be ordered that could contain information about my character, general reputation, personal and financial characteristics, and mode of living. Information on the nature and scope of such a report, if one is made, will be provided to me upon my written request. Applicant's Signature Insurance Agent's Signature Date FRAUD NOTICE: You are or may be violating state law or committing a crime knowingly to provide false, incomplete or misleading material information to an insurance company for the purpose or intent of defrauding the company. Penalties may include imprisonment, fines, denial of insurance benefits, and may subject you to civil damages. MC-AP-MA (10/12) American Modern Insurance Group 2012

3 U N I T 4 U N I T 3 U N I T 2 U N I T 1 AMERICAN MODERN HOME INSURANCE COMPANY MASSACHUSETTS RIDERS CHOICE PROGRAM APPLICATION Policy # 077 Agency Code # Agency Name Address City, State & Zip Phone Number ( ) Previous AMIG Policy # Subproducer # Sub Name Address City, State & Zip Phone Number ( ) BASIC / CLIENT INFORMATION Titled Owner / First Name Middle Initial Titled Owner / Last Name Home Phone ( ) Work Phone ( ) Mailing Address (Street) City State Zip Effective Date Is mailing address the Total # of Operators Total # of Units same as Unit 1 address? (Including Excluded Operators) Term Yes No 12 Month ADDITIONAL INSURED INFORMATION (IF N/A, DO NOT COMPLETE) First Name Last Name Mailing Address (Street) City Birthday State Zip (MM/DD/YYYY) Social Security Number Occupation Additional Insured Type Joint Owner Lienholder Other OPERATOR INFORMATION (ALL INFORMATION REQUIRED) OP Marital Gender Birthdate Driver's License Current # First Name Last Name Social Security Number Status (M/F) (MMDDYY) License # State MVR (Y/N) Occupation OP Year Began Driving Valid Cycle SR-22 Excluded Operator Cycle Driver Training # Primary Residence Street Driven Units License (Y/N) (Y/N) (Y/N) (MM/DD/YYYY) 1 Own Rent Live w/ Parent Other 2 Own Rent Live w/ Parent Other 3 Own Rent Live w/ Parent Other 4 Own Rent Live w/ Parent Other 5 Own Rent Live w/ Parent Other ACCIDENT / VIOLATION INFORMATION List all traffic law violations, accidents (regardless of fault) and any insurance losses for all operators in the last 3 years (start with the most recent). Operator Incident Date Loss Operator Incident Date Loss # Accident or Violation Type (MM/DD/YYYY) Amount # Accident or Violation Type (MM/DD/YYYY) Amount UNIT INFORMATION MC-AP-MA (10/12)

4 U N I T 1 U N I T 2 U N I T 3 U N I T 4 Coverage Eligibility Questions UNIT 1 UNIT 2 UNIT 3 UNIT 4 Yes No Yes No Yes No Yes No 1. Garaged in city limits? 2. Is unit re-titled WITH a State Assigned VIN? 3. Is unit street driven? 4. Total limit of accessories, sidecars and/or Trailers? Underwriting Questions (ANY YES ANSWER DEEMS THE ENTIRE RISK INELIGIBLE.) Yes No 1. Any unit salvaged or non-factory built WITHOUT a State Assigned VIN? 2. Any unit titled in the name of a corporation? or business? 3. Any unit classified as a home-made kit motorcycle? 4. Does any unit have titled owners that reside in separate households? 5. Any unit designed/used for racing? Indicate current or previous carrier. Carrier Name: CURRENT / PREVIOUS INSURANCE Carrier Name: Carrier Name: COVERAGE SUMMARY UNIT 1 UNIT 2 UNIT 3 UNIT 4 Class/Sub-class Coverage Selection (see guidelines for coverage Limit/ Limit/ Limit/ Limit/ eligibility and requirements) Deductible Premium Deductible Premium Deductible Premium Deductible Premium Mandatory Coverages (limits must match for all units) Carrier Name: Bodily Injury (20/40; 25/50; 50/100; 100/300; 250/500) Property Damage (5,000; 10,000; 25,000; 50,000; 100,000) Optional Coverages Personal Injury Protection (1,000 Deductible) Yes No Yes No Yes No Yes No Comprehensive (100; 250; 500; 1,000 Deductible) Collision (100; 250; 500; 1,000 Deductible) Accessories Safety Apparel (1,000 Included with Collision Coverage) Discounts/Surcharges Applied Yes No Yes No Yes No Yes No Homeowner Discount Yes No Yes No Yes No Yes No Transfer Discount 1 Yes No Yes No Yes No Yes No Transfer Discount 2 Yes No Yes No Yes No Yes No Multi-Unit Discount Yes No Yes No Yes No Yes No Driving Record Surcharge Yes No Yes No Yes No Yes No Unverifiable MVR Surcharge Yes No Yes No Yes No Yes No Ineligible Risk Surcharge Yes No Yes No Yes No Yes No Total Unit Premium (reflects discounts and/or surcharges) Total Policy Premium (reflects discounts and/or surcharges) BILLING INFORMATION When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. Policy Term Payment Plan Minimum Down Payment Down Payment Method Payment Received EFT Bank ABA# EFT Account Number EFT Account Type Eff. Day of Month(1-28) Credit Card Type Credit Card Number Expiration Date(MMDDYYYY) AGENT REMARKS APPLICANT'S STATEMENT I affirm that the information provided is true and to the best of my knowledge and that no material information has been withheld. I also confirm that the Coverages and Limits described above are the Coverages and Limits I desire. I hereby authorize appropriate state authorities to release my motor vehicle driving record to American Modern Home Insurance Company or its representative. This release shall remain in effect until I request in writing that it be withdrawn. I understand that as part of routine procedures, a consumer report may be ordered that could contain information about my character, general reputation, personal and financial characteristics, and mode of living. Information on the nature and scope of such a report, if one is made, will be provided to me upon my written request. Applicant's Signature Insurance Agent's Signature Date FRAUD NOTICE: You are or may be violating state law or committing a crime knowingly to provide false, incomplete or misleading material information to an insurance company for the purpose or intent of defrauding the company. Penalties may include imprisonment, fines, denial of insurance benefits, and may subject you to civil damages. MC-AP-MA (10/12) American Modern Insurance Group 2012

5 AMERICAN MODERN HOME INSURANCE COMPANY RIDERS CHOICE PROGRAM EXPLANATORY MEMORANDUM/FORMS American Modern Home Insurance Company is submitting a form filing for your review. We are requesting that Form # MC-AP-MA Application has replaced the edition date from (07/07) to (10/12). The replacement edition contains new disclosure language on the application. We request to make this change effective October 15 th, 2012 for new business and effective October 15 th, 2012 for renewal business.

6 MASSACHUSETTS AMERICAN MODERN HOME INSURANCE COMPANY RIDERS CHOICE PROGRAM FORMS SECTION Form Number Title Form Type VA000 (07/06) Riders Choice Off Road Policy Policy Form (5/92) Free Form Declarations Page (currently in use) Dec (10/07) Free Form Declarations Page (rolled out with the implementation of our new processing system) Dec MC-AP-MA (01/07) Riders Choice Application - Massachusetts (currently in use) App MC-AP-MA (10/12) Riders Choice Application - Massachusetts (rolled our with the implementation of our new processing system) App MC-AP-OV (01/07) Riders Choice Application Overflow App JENRI Cancellation Notice Cancellation Notice JENRIC - 16 Non-Renewal Notice Non-Renewal Notice VMD20 (10/06) Motorcycle Driver Exclusion Endorsement - Massachusetts Endorsement VAP20 (10/06) Riders Choice Off Road Policy Personal Injury Protection Endorsement - Massachusetts Endorsement V67MA (10/06) Selection or Rejection of Personal Injury Protection Coverage- Massachusetts Selection/Rejection Form V9295 (11/05) Summary of Rights Other G-MVR MVR FCRA Notice Other G-CLUE CLUE FCRA Notice Other PVS00 Privacy Statement Other NEW PAGE X PAGE NUMBER EFFECTIVE DATE PUBLICATION DATE REVISION F-1

7 DiffPDF U:/EAST REGION MC APPLICATIONS/MA/Current Forms Page.pdf vs. U:/EAST REGION MC APPLICATIONS/MA/Proposed Forms Changes.pdf

8 DiffPDF U:/EAST REGION MC APPLICATIONS/MA/Current Application.pdf vs. U:/EAST REGION MC APPLICATIONS/MA/MC-AP-MA pdf

9 DiffPDF U:/EAST REGION MC APPLICATIONS/MA/Current Application.pdf vs. U:/EAST REGION MC APPLICATIONS/MA/MC-AP-MA pdf