Is this application to: Apply for new automobile insurance

SM6-1: Insurance Application Is this application to: Apply for new automobile insurance Update existing application Applicant s Contact Information Lessor s Contact Information (if applicable) Policy Period Effective date (mm-dd-yy): Expiration date (mm-dd-yy): Time: am pm Time: am pm Auto 1 2 3 Auto 1 2 3 Auto 1 2 3 Auto 1 2 3 Automobile Information Model Year Make Model Body Type of Cylinders or Engine Size Vehicle Identification Estimated Annual Driving Distance Is any automobile used for car pooling? If yes, give number of passengers and details Owned or Leased? Purchased/Leased Year Month New? Used? Type of Fuel Used Gas Purchase Price (including options & taxes) Diesel Other details Lien holder Name and Contact Information Work Commute 1 way Automobile Use Gross Vehicle Weight (lbs.) Pleasure Business Farm Commercial Unrepaired Damage? Modified or Customized? If yes, give details in remarks section? Are the automobiles registered to the applicant? (If no, give details in remarks section). Will any of the automobiles be leased or used to carry passengers for hire, to haul a trailer, or carry hazardous materials? (If no, give details in remarks section.) SM6-1: Insurance Application pg. 1 of 2

SM6-1: Insurance Application continued Driver 1 2 3 Driver 1 2 3 Driver Education Certificate Enclosed Name (as on Driver s License) Date of first license M D Y Driver Information Driver s License Number Other class of license, if applicable M D Y Previous Accidents and Insurance Claims Date of Birth M D Y Percentage use by each driver Auto Auto Auto 1 2 3 Provide details of previous accidents and insurance claims by the applicant or any driver during the last five years. Driver Auto Date Coverage claim Amount paid Details M D Y paid under or estimate use remarks section if necessary Sex Marital Status Are any other persons licensed to drive? If yes, give details in remarks section History of Convictions Provide details of convictions of applicant or any other driver involving automobiles during the last five years. Driver Date M D Y Details use remarks section if necessary Remarks Section Insurance Coverage Applied For Your insurance agent will contact you with various insurance coverage options. Due to previous accidents and history of convictions, the applicant and other drivers may not be eligible for certain types of coverage. Declaration of Applicant The information provided on this Application for Automobile Insurance is true and pertinent information has not been omitted. If the application has been falsified or does not include pertinent information, the application can be rejected. I authorize the company to collect and review any information applicable to this application, including verifying applicant contact information, lessor s contact information (if applicable), automobile information, driver information, previous accidents, insurance claims, and history of convictions. Applicant s Signature Date SM6-1: Insurance Application pg. 2 of 2

SM6-2: Insurance Claim Form Claimant s Contact Information Driver #1 Contact Information use additional paper for multiple other drivers Lessor s Contact Information (if applicable) Insurance Company and/or Agent Insurance Company and/or Agent Contact Number for Insurance Company and/or Agent Driver #2 Contact Information Contact Number for Insurance Company and/or Agent Driver #3 Contact Information Lessor s Contact Information (if applicable) Insurance Company and/or Agent Lessor s Contact Information (if applicable) Insurance Company and/or Agent Contact Number for Insurance Company and/or Agent Contact Number for Insurance Company and/or Agent Peace Officer Information Law enforcement agency Name(s) of officer(s) Law enforcement agency Name(s) of officer(s) SM6-2: Insurance Claim Form pg. 1 of 4

SM6-2: Insurance Claim Form continued Vehicle and Passenger Information use additional paper to provide details of injuries Claimant Other Driver #1 Make Model Year License Plate (State) Number of Passengers Condition of Passengers Condition of Vehicle Make Model Year License Plate (State) Number of Passengers Condition of Passengers Condition of Vehicle Other Driver #2 Other Driver #3 Make Make Model Model Year Year License Plate (State) Number of Passengers Condition of Passengers Condition of Vehicle License Plate (State) Number of Passengers Condition of Passengers Condition of Vehicle Conditions Location Time of day Date Road Conditions Weather Other conditions/factors SM6-2: Insurance Claim Form pg. 2 of 4

SM6-2: Insurance Claim Form continued Witness 1 Witness 2 Accident Write the details of the accident, providing as much detail as possible. Use additional paper if necessary. SM6-2: Insurance Claim Form pg. 3 of 4

SM6-2: Insurance Claim Form continued Diagram the accident. Accident Diagram Declaration of Claimant The information provided on this Insurance Claim Form is true and pertinent information has not been omitted. If the claim form has been falsified or does not include pertinent information, it could extend the claims process. I authorize the company to collect and review any information applicable to this claim form, including verifying witness testimony and law enforcement case reports. Claimant s Signature Date Please return this form as soon as possible to your automobile insurance agent and claims department. Remember to provide copies of any documentation. SM6-2: Insurance Claim Form pg. 4 of 4

Assessment 6-2: Evaluation Short Answer (10 pts.): Read each item carefully; then write an answer based on what you learned about risk. 1. List at three examples of risky behaviors that will potentially impact you financially now or in the next few years. (3 pts.) a. b. c. 2. List three insurance documents you should keep either in a file or in your possession. (3 pts.) a. b. c. 3. List two responsibilities of an insured person and two responsibilities of an insurance company. (4 pts.) Insured Person Insurance Company Multiple Choice (15 pts.): Read each item carefully; then select the best answer. Each answer is worth 1 pt. 4. In managing risk, what does it mean to transfer it? a. To take measures to prevent loss b. To shift the possibility of loss to another person c. To set aside resources to cover potential loss d. To take measures to eliminate the cause of potential loss 5. Liability insurance protects you against a. lawsuits. b. personal injuries. c. sickness. d. property damage. 6. When you apply for automobile insurance on your own, you will need to provide the insurance company with all of the following except a. your Social Security number. b. your employer s name and address. c. your history of driving violations. d. the vehicle identification number of the car you want to insure. Score /50 Name Date SM6-3: Assessment 6-2 Evaluation pg. 1 of 4

7. 8. 9. If you were in a car accident, which of the following is needed when you file a claim? a. A memo from the police who responded to the accident b. Your insurance policy c. A note from any witnesses or other person involved in the accident d. The address of the location where the accident occurred What coverage reimburses a car owner if the car is stolen? a. Deductible b. Collision c. Comprehensive d. Liability Which one of the following will not affect the cost of automobile insurance? a. Cost of repairs b. Mileage c. Driving record d. Color of car 10. What do you pay out-of-pocket on an automobile or property insurance claim? a. Deductible b. Liability c. Premium d. Term 11. While driving to the store, you swerved to miss a dog and drove into a tree. You and the dog are all right, but it will be expensive to repair the damage to your car. What type of automobile insurance coverage will provide reimbursement for damages to your car? a. liability coverage b. underinsured motorist c. collision d. comprehensive 12. Refer to question #11. What type of automobile insurance coverage will provide reimbursement to the property owner if the tree is damaged? a. liability coverage b. underinsured motorist c. collision d. comprehensive 13. Morgan is a safe driver. She drives a new car and has $300 in an emergency fund for any unexpected car expenses. Morgan earns $200 a month from her part-time job, and she is able to save at least $50 every month for her financial goals. Morgan is comparing her current automobile insurance with other plans to see if she can reduce her insurance expenses. Use the quote information at the right to help her decide which option is best for her situation. a. Stay with her current company and insurance plan b. Stay with her current company, but reduce the premium by $25 per month and increase the deductible to $500 c. Switch to Company X s plan d. Switch to Company Z s plan Current Company 3-month premium, $325 Deductible: $100 Minimum coverage Company X 6-month premium, $600 Deductible: $200 No collision coverage Company Z 6-month premium, $550 Deductible: $500 Minimum coverage SM6-3: Assessment 6-2 Evaluation pg. 2 of 4

14. Which of the following pairs represents the general types of insurance often provided by employers? a. liability insurance and homeowners insurance b. life insurance and liability insurance c. disability insurance and medical insurance d. homeowners insurance and disability insurance 15. There are six general types of insurance. Which of the following is one of those six? a. Liability b. Collision c. Cash value d. Uninsured motorist 16. In general, who would most need life insurance? a. A single person just beginning a career b. A young married couple with small children c. A working couple with grown children living on their own d. A retired person who is married and has investments 17. What are the two most important types of insurance you need at your young age? a. Liability and renters b. Travel and liability c. Automobile and disability d. Health and automobile 18. Which of the following could be a consequence of not having enough insurance coverage? a. Not meeting your long-term financial goals b. Not having a vehicle for transportation c. Poor credit rating d. Not being able to stick with your budget e. All of the above f. All but C Matching (5 pts.): Read each statement carefully. Select the term that best matches the statement by writing the letter of the matching term. 19. The chance of loss from some type of danger. 20. Written contract detailing what an insurance company will cover, how much it will pay, and how much you will pay. 21. The maximum amount the insurance company will pay if you file a claim. 22. The rights and responsibilities of the insured and the insurance company. 23. A request for payment to recover financial loss from damages. a. Claim b. Conditions c. Coverage Limit d. Deductible e. Insurance f. Insurance Policy g. Premium h. Risk SM6-3: Assessment 6-2 Evaluation pg. 3 of 4

True/False (10 pts.): Read each statement carefully. Show whether the statement is True (T) or False (F) by writing either T or F next to it. If a statement is false, rewrite the statement to be a true statement. (Each item is worth 2 pts.) 24. You will pay the same premium for automobile insurance as your classmates. 25. The purpose of insurance is to protect against financial loss. 26. If you choose an insurance policy with a large deductible, the premium is usually higher. 27. When you file an insurance claim for damages from an automobile accident, you decide what the costs will be to repair the damage. 28. If your family has health insurance coverage and you are a full-time student, you can be covered under the same family policy for medical expenses until you are 23 years old. Essay (10 pts.): 29. In this unit, you learned about four options to help you manage risk of potential personal or financial loss. In the chart below, give an example of how each option applies to your current situation. (4 pts.) Risk Management Options Personal Examples Avoid the Risk Reduce the Risk Accept the Risk Share the Risk 30. Use what you have learned in this unit to identify at least three types of insurance you will need in your mid-20s. List your insurance by type of insurance, and explain how the insurance protects you from financial loss. (6 pts.) Type of Insurance How It Protects You SM6-3: Assessment 6-2 Evaluation pg. 4 of 4

Assessment 6-2: Evaluation Answer Key Short Answer (10 pts.). 1. (3 pts.) Award 1 pt. for each realistic response that might have a financial impact on the student [Objective A, p. 81] 2. (3 pts.) Award up to 3 pts. for any of the following responses: current insurance policies, premium statements, inventory of property, documentation for any claims, auto insurance identification card, health insurance identification card [Objective D, p. 83] 3. (4 pts.) [Objective D, pp. 86, 89] Insured Person Insurance Company Award 1 pt. for each valid response. Possible responses: pay premium on time, notify company of any major changes that will impact coverage, promptly file claims, be truthful when applying for insurance and when filing a claim. Award 1 pt. for each valid response. Possible responses: keeping you fully informed of your policy conditions and costs, handling your claims promptly and fairly, resolving complaints in a timely manner, protecting your privacy. Multiple Choice (15 pts.). Each answer is worth 1 pt. 4. b. To shift the possibility of loss to another person [Objective A, pp. 80 81] 5. a. lawsuits [Objective B, p. 82] 6. b. your employer s name and address [Objective D, p. 88] 7. d. The address of the location where the accident occurred [Objective D, p. 89] 8. c. Comprehensive [Objective C, p. 86] 9. d. Color of car [Objective C, pp. 85, 87] 10. a. Deductible [Objective D, p. 82] 11. c. collision [Objective D, p. 86] 12. a. liability coverage [Objective D, p. 86] 13. a. Stay with her current company and insurance plan [Objective C, p. 87] 14. c. disability insurance and medical insurance [Objective E, pp. 90 91] 15. a. Liability [Objective E, p. 90] 16. b. A young married couple with small children [Objective E, p. 92] 17. d. Health and automobile [Objective E, p. 92] 18. e. All of the above [Objective E, p. 93] Matching (5 pts.). 19. h. Risk [Objective A, p. 81] 20. f. Insurance Policy [Objective B, p. 82] 21. c. Coverage Limit [Objective B, p. 82] 22. b. Conditions [Objective C, p. 86] 23. a. Claim [Objective D, p. 89] SM6-3: Assessment 6-2 Evaluation (Instructor) pg. 1 of 2

True/False (10 pts.). Each item is worth 2 pts. Award the full 2 pts. for each true response and each false response with an accurate rephrased statement. Award only 1 pt. for a correctly labeled false statement without a correctly rewritten statement. 24. False. Premiums will vary based on factors such as your driving record, what you drive, and how many vehicles are insured under one policy. Students are also eligible for good student discounts. [Objectives B, C; pp. 82 87] 25. True. [Objective B, p. 82] 26. False. A premium is typically lower for a higher deductible because the insured is taking on more financial risk. [Objective E, pp. 83, 87] 27. False. A claims adjuster will investigate the claim and work with you to make a recommendation to the insurance company. [Objective D, p. 89] 28. True. [Objective E, p. 90] Essay (10 pts.). 29. (4 pts.) [Objective A, p. 81] Risk Management Options Avoid the Risk Personal Examples Award 1 pt. for each relevant, realistic example that applies to managing risk Reduce the Risk Accept the Risk Share the Risk 30. (6 pts.) [Objective E, pp. 90 92] Award points for the following: Type of Insurance 1 3 pts. = Award 1 pt., maximum of 3 pts., for any of the following types of insurance: any health (medical, dental), automobile, any property (renters or homeowners ), disability, life, liability How It Protects You 1 3 pts. = Award 1 pt., maximum of 3 pts., for each clear, accurate, and valid explanation of how the insurance type listed will provide protection from financial loss for a young adult SM6-3: Assessment 6-2 Evaluation (Instructor) pg. 2 of 2