SUPPLEMENTAL APPLICATION FOR MASSACHUSETTS MOTOR VEHICLE INSURANCE (Complete and submit with Personal Auto Application)

Transcription

1 SUPPLEMENTAL APPLICATION FOR MASSACHUSETTS MOTOR VEHICLE INSURANCE (Cmplete and submit with Persnal Aut Applicatin) Applicant s Name Residential Address City, State & Zip Cde Address MAIP Cert# (if applicable) Prducer Name Safety Prducer Cde Effective Hme Phne Cell Phne 1. D yu have Prperty Insurance n yur Massachusetts principal place f residence? Yes N If yes, please enter the infrmatin belw. Type f Plicy Plicy Number Name f Cmpany Expiratin Hw Lng at this residence D yu have ther Insurance (nt including aut and the prperty insurance abve) with Safety Insurance? Yes N Type f Plicy Plicy Number Name f Cmpany Expiratin 2. Has any listed driver cmpleted an Advanced Driver Skill Prgram r Defensive Driver Curse? Yes N If yes, please enter the infrmatin belw. Name f Driver Name f Prgram f Certificate Cpy f Certificate (yes r n) 3. Have yu had cntinuus autmbile insurance cverage in the past 12 mnths? Yes N Have yu had cntinuus autmbile insurance cverage in the past 36 mnths? Yes N 4. D yu currently have an autmbile insurance plicy? Yes N If yes, wh is yur current insurance carrier? What is the Bdily Injury Limit (Part 5)? If yes, hw lng have yu been with yur current prducer (cntinuusly)? 5. Des any listed driver have a Freign Driver s License? Yes N If yes, hw lng have they resided in MA? If yes, please attach a cpy f the frnt and back f license and cpy f driving recrd frm license state. 6. D yu carry supplemental independent radside assistance cverage? Yes N If yes, please enter the infrmatin belw. Subscriber Name Name f Prgram Annual Cst 7. Are any f the husehld vehicle(s) used in a carpl? If yes, list the infrmatin belw. Vehicle Hw many days per mnth? Hw many passengers? SAM Page 1 f 2

2 8. D any f yur vehicles have a permanently installed Bluetth? Yes N 9. D any f yur vehicles have an active car link system installed? Yes N 10. D yu r any husehld member have an active Military status? Yes N 11. Wuld yu like t sign up fr Electrnic Plicy Issuance? Yes N 12. Wuld yu like t sign up fr Cmbined Accunt Billing (if yu have anther plicy with Safety)? Yes N 13. Are any listed drivers (inexperienced peratr) students that meet the fllwing criteria? Yes N Full time student in high schl, cllege r hme study grup r In the upper 20% class schlastically r Maintains a grade pint average f B r better r Is included n the Dean s List r Hnr Rll r cmparable list indicting schlastic achievement. Please attach any relevant dcumentatin. 14. Are any listed drivers a full-time student that resides at an educatinal institutin at least 100 miles away and des nt have regular access t a vehicle? If yes, please enter the infrmatin belw. Yes N Name f Student Name f Schl Address f Schl 15. If yu are excluding any peratrs n the plicy, please remember t attach the Operatr Exclusin Frm (signed by bth the named insured and the peratr t be excluded). 16. Are yu eligible fr any f Safety s Grup Marketing discunts? Yes N If yes, what is the name f the grup? (Fr a list f Safety s Grup Marketing discunts please cntact yur prducer.) 17. Will yu be using yur vehicle(s) in yur ccupatin, prfessin, r business (excluding cmmuting)? Yes N If yes, please describe the nature f such use: A. I declare that all the statements cntained in this Supplemental Applicatin are cmplete and true t the best f my knwledge as f this date. I understand that Safety may exchange payment f premium infrmatin and accident r claim infrmatin with my previus autmbile carrier. Signature f Applicant Signature f Prducer B. IF THIS APPLICATION IS BEING ELECTRONICALLY TRANSMITTED, THE FOLLOWING MUST ALSO BE COMPLETED: I agree t be bund by this electrnic recrd and it shall have the same legal frce and effect as the written applicatin. Signature f Applicant Signature f Prducer Fr detailed infrmatin abut Safety s discunt prgram (specific discunt percentages and descriptins) please visit us at SAM Page 2 f 2

3 APPLICATION FOR MASSACHUSETTS MOTOR VEHICLE INSURANCE PRODUCER CODE: APPLICANT'S NAME, RESIDENTIAL ADDRESS AND ZIP PHONE: BINDER/POLICY #: EFFECTIVE DATE EXPIRATION DATE MAIL ADDRESS (IF DIFFERENT) [COMPANY USE] DIRECT BILL PAYMENT PLAN DEPOSIT PREMIUM AGENCY BILL COVERAGE INFORMATION: Massachusetts Law requires that if a cmpany elects t prvide Cmpulsry Insurance Cverage (Parts 1,2,3,4), it must als ffer the fllwing Optinal Cverages: Optinal Bdily Injury t Others, Bdily Injury Caused by An Uninsured Aut, Bdily Injury Caused By An Underinsured Aut at limits up t 35,000 each persn, 80,000 each accident, Medical Payments Cverage up t 5,000, Cllisin, Limited Cllisin, Cmprehensive and Substitute Transprtatin. Hwever, Part 7, Cllisin, Part 8, Limited Cllisin, and Part 9, Cmprehensive cverages may be refused r cancelled in certain situatins as prvided fr in the law. Part 11, Twing and Labr Cverage is available at the ptin f the Cmpany. COVERAGES PARTS COMPULSORY INSURANCE LIMITS/DEDUCTIBLE PREMIUM LIMITS/DEDUCTIBLE PREMIUM 1. BODILY INJURY TO OTHERS 20,000 PER PERSON/40,000 PER ACCIDENT 20,000 PER PERSON/40,000 PER ACCIDENT 2. PERSONAL INJURY PROTECTION 8,000 PER PERSON YOURSELF 8,000 PER PERSON YOURSELF 3. BODILY INJURY CAUSED BY AN UNINSURED (COMPULSORY LIMITS 20,000/40,000) DED YOURSELF & HOUSEHOLD MEMBERS PER PERSON PER ACCIDENT 4. DAMAGE TO SOMEONE ELSE'S PROPERTY (COMPULSORY LIMIT 5,000) PER ACCIDENT DED YOURSELF & HOUSEHOLD MEMBERS PER PERSON PER ACCIDENT PER ACCIDENT OPTIONAL INSURANCE 5. OPTIONAL BODILY INJURY TO PER PERSON PER PERSON OTHERS PER ACCIDENT PER ACCIDENT 6. MEDICAL PAYMENTS PER PERSON PER PERSON 7. COLLISION ACV 8. LIMITED COLLISION ACV 9. COMPREHENSIVE ACV 10. SUBSTITUTE TRANSPORTATION UP TO 11. TOWING AND LABOR UP TO WAIVER OF DEDUCTIBLE 100 GLASS DEDUCTIBLE DED WAIVER OF DED DEDUCTIBLE DED DED DED 100 GLASS DEDUCTIBLE A DAY, MAXIMUM UP TO FOR EACH DISABLEMENT UP TO DED A DAY, MAXIMUM FOR EACH DISABLEMENT 12. BODILY INJURY CAUSED BY AN PER PERSON PER PERSON UNDERINSURED PER ACCIDENT PER ACCIDENT MERIT RATING PLAN PREMIUM ADJUSTMENT PREMIUM ADJUSTMENT GUEST OCCUPANT EXCLUSION FOR MOTORCYCLE VEHICLE INFORMATION PLACE OF PRINCIPAL GARAGING - 1: STREET ADDRESS,CITY OR TOWN ZIP CODE # YEAR MAKE, MODEL AND, IF MOTORCYCLE, C.C. 1 2 # AIR BAG/ PASSIVE SEAT BELT (YES/NO) ANTI- THEFT (YES/NO) VEHICLE RECOVERY SYSTEM (YES/NO) VEHICLE IDENTIFICATION NUMBER LEASED (YES/NO) PREMIUM GROSS VEHICLE WEIGHT RATING FOR VAN OR PICK- UP PREMIUM * REGISTRATION PLATE NUMBER 2: DATE OF PURCHASE SECURED LENDER AND/OR LESSOR (Please include name and address) VEHICLE COST NEW OR MOTORCYCLE AVERAGE RETAIL VALUE TOTAL PREMIUM MILES WAS DRIVEN IN PAST 12 MOS 1 2 NOTICE: Evidence f installatin f an anti-theft device r a vehicle recvery system is required t receive a discunt fr Part 9, Cmprehensive. If yur aut is nt equipped with an anti-theft device r a vehicle recvery system and yur aut is n the High-Theft Vehicle List furnished with this applicatin, yu may be charged an Extra-Risk rate fr Part 9, Cmprehensive. DRIVER INFORMATION ODOMETER READING Furnish infrmatin fr the applicant and each individual wh custmarily perates the aut(s) whether r nt a Husehld Member. Yur failure t list a husehld member r any individual wh custmarily perates yur aut may have very serius cnsequences. OPERATOR NAME DATE OF BIRTH CURRENT DRIVER'S LICENSE # /LICENSED STATE If licensed in anther state r cuntry within the last 6 years, als indicate that state r cuntry and the license number. MERIT RATING POINTS MASS DATE FIRST LICENSED OTHER MOTOR CYCLE DRIVER TRAINING YES / NO 1 2 % OF USE NOTICE It is a crime t knwingly prvide false r fraudulent infrmatin fr the purpse f defrauding an insurance cmpany. If yu r smene else n yur behalf knwingly gives us false, deceptive, misleading r incmplete infrmatin in this applicatin and if such false, deceptive, misleading r incmplete infrmatin increases ur risk f lss, we may refuse t pay claims under any r all f the Optinal Insurance Parts and we may cancel yur plicy. Such infrmatin includes the descriptin and the place f garaging f the vehicle(s) t be insured, the names f all husehld members and custmary peratrs required t be listed and the answers given abve fr all listed peratrs. Yu must ntify us f changes that have ccurred prir t the renewal f this plicy and during the plicy perid. We may als limit ur payments under Part 3 and Part 4. We will nt pay fr a cllisin r limited cllisin lss fr an accident which ccurs while yur aut is being perated by a husehld member wh is nt listed as an peratr n yur plicy. Payment is withheld when the husehld member, if listed, wuld require the payment f additinal premium n yur plicy because the husehld member wuld be classified as an inexperienced peratr r wuld require payment f additinal premium n yur plicy under the Merit Rating Plan. PLEASE CONTINUE AND COMPLETE INFORMATION ON REVERSE

4 DRIVER INFORMATION (CONTINUED) A. BEEN INVOLVED IN ANY MOTOR VEHICLE ACCIDENT OR BEEN FOUND GUILTY OF ANY MOVING VIOLATION? Explain all Yes respnses in the REMARKS Sectin. During the last six years have yu r any listed peratr: YES NO D. BEEN CONVICTED OF VEHICULAR HOMICIDE, RELATED FRAUD, THEFT, OR DRIVING UNDER THE INFLUENCE OF ALCOHOL OR DRUGS? B. BEEN ASSIGNED TO AN ALCOHOL EDUCATION PROGRAM? E. RECEIVED PAYMENT FROM AN INSURANCE COMPANY FOR ANY COMPREHENSIVE CLAIM? C. HAD TWO OR MORE TOTAL FIRE OR TOTAL THEFT CLAIMS? F. HAD YOUR LICENSE REVOKED OR SUSPENDED? YES NO LICENSE INFORMATION Once yu r the principal peratr listed n this applicatin becme a resident f Massachusetts, yu r the principal peratr must btain a Massachusetts driver s license. A resident f anther state may drive in Massachusetts with a currently valid license issued by the individual s state f residence. A visitr frm anther cuntry wh is at least 18 years ld and has a valid license issued by a cuntry accepted by the Registrar f Mtr Vehicles (in accrdance with the 1949 Rad Traffic Cnventin r the 1943 Inter-American Autmtive Traffic Cnventin) may legally drive in Massachusetts fr up t ne year frm the date f arrival in the United States. The failure by yu r the principal peratr t be prperly licensed t perate a mtr vehicle in Massachusetts may result in the nn-renewal f the autmbile insurance plicy. Fr infrmatin abut the Massachusetts requirements fr driver s licenses, please cnsult the Registry f Mtr Vehicle s website at MERIT RATING INFORMATION A If in the last six years any listed peratr had a driver s license in the United States r certain cuntries whse recrds are electrnically available, we will btain that fficial driving recrd(s) which will be used in assigning merit rating pints. GENERAL INFORMATION Explain all Yes" respnses in the REMARKS Sectin; n Questins 3-8 include the aut number. 1. DO YOU PRESENTLY OWE ANY MOTOR VEHICLE PREMIUM, PAYABLE IN THE LAST TWELVE MONTHS? 2. HAS YOUR MOBILE INSURANCE POLICY BEEN CANCELED OR NON- RENEWED FOR ANY REASON IN THE LAST THREE YEARS? 3. ARE ANY LISTED OPERATORS INCLUDED ON ANOTHER POLICY OR DO THEY HAVE THEIR OWN MASSACHUSETTS PERSONAL MOBILE POLICY? (LIST OPERATOR #, INSURANCE COMPANY, AND POLICY#) 4. IF A VEHICLE IS A MOTORCYCLE, HAS THE PRINCIPAL OPERATOR COMPLETED AN APPROVED MOTORCYCLE RIDER TRAINING PROGRAM? (ATTACH COPY OF CERTIFICATE OR OTHER EVIDENCE OF COMPLETION) YES NO 5. IS ANY USED TO TRANSPORT (T r Frm Wrk r Schl): A. FELLOW EMPLOYEES, PASSENGERS OR STUDENTS, FOR A FEE? B. PERSONS EMPLOYED BY YOU? 9. IF ANY (S) TO BE INSURED IS TITLED WITH A SALVAGE TITLE ISSUED BY THE MASS REGISTRY OF MOTOR VEHICLES, PLEASE INDICATE. (Salvage Title Vehicles Are Nt Eligible fr Cverage Parts 7, 8, r 9) 6. IS ANY VAN OR PICK-UP EQUIPPED WITH CUSTOM FURNISHINGS OR CUSTOM EQUIPMENT? (If Yes, Yu May Wish t Purchase Additinal Cverage.) 7. IS ANY EQUIPPED WITH ELECTRONIC EQUIPMENT PERMANENTLY INSTALLED BUT NOT IN LOCATIONS USED BY THE MANUFACTURER FOR SUCH EQUIPMENT? (If Yu Wish t Purchase Cverage Fr these Items, list Make, Mdel, Serial #, Amunt f Ins. fr Items). 8. IS ANY USED IN BUSINESS? (Type f Business) A. IF VAN/PICK-UP, IS IT USED TO DELIVER/TRANSPORT GOODS? B. IS GROSS VEHICLE WEIGHT 10,000 POUNDS OR MORE? 1 2 APPRAISAL 10. IF ANY (S) LISTED ON THE APPLICATION IS CONSIDERED TO BE AN ANTIQUE AND YOU WISH TO PURCHASE COVERAGE PARTS 7, 8 OR 9, ATTACH A COPY OF THE CURRENT APPRAISAL. 11. IF THIS APPLICATION IS FOR A MOTORCYCLE, TRAILER OR RECREATIONAL VEHICLE, AN ANNUAL POLICY WILL BE ISSUED UNLESS INDICATED BELOW: REMARKS MOTORCYCLE ONLY - ISSUE MY POLICY TO EXPIRE AT 12:01 A.M. ON JANUARY 1ST AND DO NOT RENEW. TRAILER OR RECREATIONAL VEHICLE - ISSUE MY POLICY TO EXPIRE AT 12:01 A.M. ON DECEMBER 1ST AND DO NOT RENEW. IF ADDITIONAL SPACE IS REQUIRED, ATTACH ADDITIONAL SHEET(S) OF PAPER. ATTACHMENTS ANTI-THEFT DEVICE CERTIFICATE APPROVED DRIVER TRAINING CERTIFICATE YES APPROVED MOTORCYCLE RIDER TRAINING CERTIFICATE. CUSTOMIZED EQUIPMENT EVIDENCE OPERATOR EXCLUSION FORM OUT-OF-STATE DRIVER RECORD PRE-INSURANCE FORM VEHICLE RECOVERY SYSTEM CERTIFICATE NO FAIR CREDIT REPORTING ACT: In cnnectin with yur applicatin fr insurance and as part f ur nrmal underwriting prcedure, an investigative cnsumer reprt may be btained, including, if applicable, infrmatin as t character, general reputatin, persnal characteristics and mde f living. This infrmatin is btained thrugh persnal interviews with yur friends, neighbrs and assciates. Upn written request, received within a reasnable time, additinal detailed infrmatin cncerning the nature and scpe f this investigatin will be prvided. DECLARATIONS AND SIGNATURES I DECLARE THAT ALL THE STATEMENTS CONTAINED IN THIS APPLICATION ARE COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE AS OF THIS DATE. I UNDERSTAND THAT THE COMPANY MAY EXCHANGE PAYMENT OF PREMIUM INFORMATION AND ACCIDENT OR CLAIM INFORMATION WITH MY PREVIOUS MOBILE INSURANCE COMPANY. Signature f Applicant and Time TO BE COMPLETED BY AGENT: The infrmatin cntained in this applicatin is as tld t me by the applicant and is true and cmplete t the best f my knwledge. Signature f Agent and Time IF THIS APPLICATION IS BEING ELECTRONICALLY TRANSMITTED, THE FOLLOWING MUST ALSO BE COMPLETED: I agree t be bund by this electrnic recrd and it shall have the same legal frce and effect as the written applicatin. Applicant s Name 2008

5 SUPPLEMENTAL APPLICATION FOR MASSACHUSETTS MOTOR VEHICLE INSURANCE (Cmplete and submit with Persnal Aut Applicatin) Applicant s Name Residential Address City, State & Zip Cde Address MAIP Cert# (if applicable) Prducer Name Safety Prducer Cde Effective Hme Phne Cell Phne 1. D yu have Prperty Insurance n yur Massachusetts principal place f residence? Yes N If yes, please enter the infrmatin belw. Type f Plicy Plicy Number Name f Cmpany Expiratin Hw Lng at this residence D yu have ther Insurance (nt including aut and the prperty insurance abve) with Safety Insurance? Yes N Type f Plicy Plicy Number Name f Cmpany Expiratin 2. Has any listed driver cmpleted an Advanced Driver Skill Prgram r Defensive Driver Curse? Yes N If yes, please enter the infrmatin belw. Name f Driver Name f Prgram f Certificate Cpy f Certificate (yes r n) 3. Have yu had cntinuus autmbile insurance cverage in the past 12 mnths? Yes N Have yu had cntinuus autmbile insurance cverage in the past 36 mnths? Yes N 4. D yu currently have an autmbile insurance plicy? Yes N If yes, wh is yur current insurance carrier? What is the Bdily Injury Limit (Part 5)? If yes, hw lng have yu been with yur current prducer (cntinuusly)? 5. Des any listed driver have a Freign Driver s License? Yes N If yes, hw lng have they resided in MA? If yes, please attach a cpy f the frnt and back f license and cpy f driving recrd frm license state. 6. D yu carry supplemental independent radside assistance cverage? Yes N If yes, please enter the infrmatin belw. Subscriber Name Name f Prgram Annual Cst 7. Are any f the husehld vehicle(s) used in a carpl? If yes, list the infrmatin belw. Vehicle Hw many days per mnth? Hw many passengers? SAM Page 1 f 2

6 8. D any f yur vehicles have a permanently installed Bluetth? Yes N 9. D any f yur vehicles have an active car link system installed? Yes N 10. D yu r any husehld member have an active Military status? Yes N 11. Wuld yu like t sign up fr Electrnic Plicy Issuance? Yes N 12. Wuld yu like t sign up fr Cmbined Accunt Billing (if yu have anther plicy with Safety)? Yes N 13. Are any listed drivers (inexperienced peratr) students that meet the fllwing criteria? Yes N Full time student in high schl, cllege r hme study grup r In the upper 20% class schlastically r Maintains a grade pint average f B r better r Is included n the Dean s List r Hnr Rll r cmparable list indicting schlastic achievement. Please attach any relevant dcumentatin. 14. Are any listed drivers a full-time student that resides at an educatinal institutin at least 100 miles away and des nt have regular access t a vehicle? If yes, please enter the infrmatin belw. Yes N Name f Student Name f Schl Address f Schl 15. If yu are excluding any peratrs n the plicy, please remember t attach the Operatr Exclusin Frm (signed by bth the named insured and the peratr t be excluded). 16. Are yu eligible fr any f Safety s Grup Marketing discunts? Yes N If yes, what is the name f the grup? (Fr a list f Safety s Grup Marketing discunts please cntact yur prducer.) 17. Will yu be using yur vehicle(s) in yur ccupatin, prfessin, r business (excluding cmmuting)? Yes N If yes, please describe the nature f such use: A. I declare that all the statements cntained in this Supplemental Applicatin are cmplete and true t the best f my knwledge as f this date. I understand that Safety may exchange payment f premium infrmatin and accident r claim infrmatin with my previus autmbile carrier. Signature f Applicant Signature f Prducer B. IF THIS APPPLICATION IS BEING ELECTRONICALLY TRANSMITTED, THE FOLLOWING MUST ALSO BE COMPLETED: I agree t be bund by this electrnic recrd and it shall have the same legal frce and effect as the written applicatin. Signature f Applicant Signature f Prducer Fr detailed infrmatin abut Safety s discunt prgram (specific discunt percentages and descriptins) please visit us at SAM Page 2 f 2

7 SUPPLEMENTAL APPLICATION FOR MASSACHUSETTS MOTOR VEHICLE INSURANCE (Cmplete and submit with Persnal Aut Applicatin) Applicant s Name Residential Address City, State & Zip Cde Address MAIP Cert# (if applicable) Prducer Name Safety Prducer Cde Effective Hme Phne Cell Phne 1. D yu have Prperty Insurance n yur Massachusetts principal place f residence? Yes N If yes, please enter the infrmatin belw. Type f Plicy Plicy Number Name f Cmpany Expiratin Hw Lng at this residence D yu have ther Insurance (nt including aut and the prperty insurance abve) with Safety Insurance? Yes N Type f Plicy Plicy Number Name f Cmpany Expiratin 2. Has any listed driver cmpleted an Advanced Driver Skill Prgram r Defensive Driver Curse? Yes N If yes, please enter the infrmatin belw. Name f Driver Name f Prgram f Certificate Cpy f Certificate (yes r n) 3. Have yu had cntinuus autmbile insurance cverage in the past 12 mnths? Yes N Have yu had cntinuus autmbile insurance cverage in the past 36 mnths? Yes N 4. D yu currently have an autmbile insurance plicy? Yes N If yes, wh is yur current insurance carrier? What is the Bdily Injury Limit (Part 5)? If yes, hw lng have yu been with yur current prducer (cntinuusly)? 5. Des any listed driver have a Freign Driver s License? Yes N If yes, hw lng have they resided in MA? If yes, please attach a cpy f the frnt and back f license and cpy f driving recrd frm license state. 6. D yu carry supplemental independent radside assistance cverage? Yes N If yes, please enter the infrmatin belw. Subscriber Name Name f Prgram Annual Cst 7. Are any f the husehld vehicle(s) used in a carpl? If yes, list the infrmatin belw. Vehicle Hw many days per mnth? Hw many passengers? SAM Page 1 f 2

8 8. D any f yur vehicles have a permanently installed Bluetth? Yes N 9. D any f yur vehicles have an active car link system installed? Yes N 10. D yu r any husehld member have an active Military status? Yes N 11. Wuld yu like t sign up fr Electrnic Plicy Issuance? Yes N 12. Wuld yu like t sign up fr Cmbined Accunt Billing (if yu have anther plicy with Safety)? Yes N 13. Are any listed drivers (inexperienced peratr) students that meet the fllwing criteria? Yes N Full time student in high schl, cllege r hme study grup r In the upper 20% class schlastically r Maintains a grade pint average f B r better r Is included n the Dean s List r Hnr Rll r cmparable list indicting schlastic achievement. Please attach any relevant dcumentatin. 14. Are any listed drivers a full-time student that resides at an educatinal institutin at least 100 miles away and des nt have regular access t a vehicle? If yes, please enter the infrmatin belw. Yes N Name f Student Name f Schl Address f Schl 15. If yu are excluding any peratrs n the plicy, please remember t attach the Operatr Exclusin Frm (signed by bth the named insured and the peratr t be excluded). 16. Are yu eligible fr any f Safety s Grup Marketing discunts? Yes N If yes, what is the name f the grup? (Fr a list f Safety s Grup Marketing discunts please cntact yur prducer). 17. Will yu be using yur vehicle(s) in yur ccupatin, prfessin, r business (excluding cmmuting)? Yes N If yes, please describe the nature f such use: A. I declare that all the statements cntained in this Supplemental Applicatin are cmplete and true t the best f my knwledge as f this date. I understand that Safety may exchange payment f premium infrmatin and accident r claim infrmatin with my previus autmbile carrier. Signature f Applicant Signature f Prducer B. IF THIS APPPLICATION IS BEING ELECTRONICALLY TRANSMITTED, THE FOLLOWING MUST ALSO BE COMPLETED: I agree t be bund by this electrnic recrd and it shall have the same legal frce and effect as the written applicatin. Signature f Applicant Signature f Prducer Fr detailed infrmatin abut Safety s discunt prgram (specific discunt percentages and descriptins) please visit us at SAM Page 2 f 2