ACORD ASSOCIATED AUTO INSURERS PLAN OF SOUTH CAROLINA TM PRIVATE PASSENGER APPLICATION SECTION 1 - PRODUCER OF RECORD Producer Last Name / ncy Name Producer First Name Producer M I Mailing Address Suite / Apt # City State Zip Code Tax ID or Social Security # Producer License # Telephone # (include area code) Fax # (include area code) SECTION 2 - SIGNING PRODUCER (Complete only if the producer completing and signing this application differs from the Producer of Record.) Last Name First Name M I Tax ID or Social Security # SECTION 3 - APPLICANT Last Name First Name M I Home Tel # (include area code) Bus Tel # (include area code) Co-Applicant s Last Name (if applicable) First Name M I Fire District Street Address Suite / Apt # City State Zip Code Applicant s Former Street Address (past 3 years) Suite / Apt # City State Zip Code SECTION 4 - OPERATOR INFORMATION (List ALL operators in household and any other customary drivers.) Applicant and Other Drivers Relationship to Applicant % Use of each Vehicle # 1 # 2 # 3 # 4 Birth Date (Mo./Day/Yr.) Sex M / F * MS Driver s License # State Licensed 3 Years? If List Date Issued 1 APPLICANT APPLICANT 2 3 4 * MS Marital Status: S Single, M Married, W Widowed, D Divorced, P Separated Applicant s Occupation Nature of Employer Name Street Address City State Zip Code Driver # 2 Occupation Nature of Employer Name Street Address City State Zip Code STAPLE CHECK HERE: Send completed application, in duplicate, with check / money order and required attachments to: Associated Auto Insurers Plan of South Carolina c/o AIPSO 302 Central Avenue Johnston, RI 02919 Note: for items where space is insufficent, use Remarks Section ACORD CORPORATION 1999 Page 1 of 6
SECTION 5 - VEHICLE 1 - VEHICLE INFORMATION AND USE * If, detail in Remarks Section Miles one way to work, Annual State VEHICLE 2 - VEHICLE INFORMATION AND USE * If, detail in Remarks Section Miles one way to work, Annual State VEHICLE 3 - VEHICLE INFORMATION AND USE * If, detail in Remarks Section Miles one way to work, Annual State VEHICLE 4 - VEHICLE INFORMATION AND USE * If, detail in Remarks Section Miles one way to work, Annual State Page 2 of 6
SECTION 6 - COVERAGES (As provided by the Rules of the Plan) Same limits of liability must be purchased for all vehicles. Check appropriate box for coverage. Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Combined Single Limit Liability (CSL) 40,000 75,000 250,000 500,000 50,000 100,000 350,000 Bodily Injury Liability 15 / 30,000 50 / 100,000 250 / 500,000 25 / 50,000 100 / 300,000 Property Damage Liability 10,000 50,000 25,000 100,000 Medical Payments Coverage 1,000 5,000 2,000 Physical Damage Comprehensive ACV (no deductible) 50 200 500 2,500 100 250 1,000 5,000 Physical Damage Collision 100 250 1,000 200 500 2,500 5,000 Financial Responsibility Certificate If, indicate surcharge for appropriate vehicle(s). Uninsured Motorist (UM) Combined Single Limit 40,000 75,000 250,000 500,000 50,000 100,000 350,000 Bodily Injury 15 / 30,000 50 / 100,000 250 / 500,000 25 / 50,000 100 / 300,000 Property Damage ( 200 Deductible) 10,000 50,000 25,000 100,000 Underinsured Motorist (UIM) Combined Single Limit 40,000 75,000 250,000 500,000 50,000 100,000 350,000 Bodily Injury 15 / 30,000 50 / 100,000 250 / 500,000 25 / 50,000 100 / 300,000 Property Damage 10,000 50,000 25,000 100,000 Total Penalty Points Premium Surcharge Total Premium per Vehicle Total Premium for Vehicles 1-4 SECTION 7 - FINANCIAL RESPONSIBILITY (Complete if applicant or other eligible operator is required to file evidence of financial responsibility.) Name Case or File # Relationship to Applicant Resides with Applicant State where Filing required Reason for Filing Type of Filing Owner s (operation of owned vehicles) Operator s (operation of non-owned vehicles) Both Do you own any other vehicle If, list name of insurance company. If, list policy number. SECTION 8 - PAYMENT PLANS Option 1 - Full Annual Premium Option 2-30 % Premium Deposit with Single Bill Balance Option 3-40 % Installment Premium * (4.00 per installment charge) Premium to be Financed * * Name of Finance Company: Payment by Cash Check / Draft # Check * Not available on premium financed policies Total Premium * * Attach a copy of Premium Finance contract Amount Submitted with Application REMARKS Page 3 of 6
SECTION 9 - INSURANCE RECORD Has the applicant had insurance in the past? If, complete the following. Name of Applicant s latest carrier Policy # Termination Date (Mo./Day/Yr.) Was coverage through the Plan? Was three year assignment completed? If, list reason terminated. Are any other vehicles owned by any member of household? If, list name of insurer. Policy # Name of insurance agent and/or insurer who has rejected the applicant for automobile insurance: List reason why the applicant is submitting an application to the AAIP. (Information shall include data on traffic violations, accidents and/or reasons as to why the voluntary market has not provided coverage.) SECTION 10 - ACCIDENTS Has the applicant, or anyone who usually drives the applicant s motor vehicle(s), been involved, either as owner or operator, in ANY motor vehicle accident during the past THIRTY-SIX months? If, complete the following. (If necessary, use Remarks Section.) Name of Operator Accident Date (Mo./Day/Yr.) Place of Accident City State Bodily Injury or Death Prop. Damage Amount (inc. your own) Penalty Points If the answer to any of the following is, check box and list date of accident. Date(s) of Accident (Mo./Day/Yr.) 1. Applicant s motor vehicle lawfully parked. 2. Applicant reimbursed by or on behalf of person responsible for accident or has judgement against such person. 3. Applicant struck in rear by another auto, applicant not convicted of a violation. 4. Other person involved in accident was convicted. Applicant or operator was not convicted. 5. Damaged by "Hit-and-Run" driver and accident reported to the police within 24 hours from time of accident. 6. Other type of accident - non-chargeable under provisions of the Plan. If, describe in Remarks Section. SECTION 11 - MOVING TRAFFIC CONVICTIONS Has the applicant, or anyone who usually drives the applicant s motor vehicle(s), been CONVICTED or FORFEITED BAIL at any time during the immediately preceding THIRTY-SIX months? If, complete the following. (If necessary, use Remarks Section.) TE: A paid ticket or fine is an admission of guilt and therefore constitutes a conviction. Name of Operator Date of Conviction (Mo./Day/Yr.) Did Conviction Arise as a Result of an Accident? Type of Violation Place of Conviction City State Penalty Points Was License Suspended or Revoked? REMARKS Page 4 of 6
SECTION 12 - NAMED N - OWNER (Applicants must complete both Sections 12 and 13) A. Type of vehicle applicant will operate. Private Passenger Commercial Taxi / Bus Other (describe): B. Will vehicle be operated in applicant s occupation or business? C. Is vehicle owned by applicant or member of household? D. If answer to B or C is, list name of Insurance Company providing liability coverage: E. Is applicant excluded? SECTION 13 - STATUTORY REGISTRATION TICE FOR NAMED N-OWNER APPLICANTS NAMED N-OWNER APPLICANTS MUST COMPLETE SECTION 13 SECTION 56-10-250: Unlawful to sell vehicle with suspended registration to family member. It is unlawful for any vehicle owner to sell or otherwise dispose of any motor vehicle, for which the registration and license plates have been suspended, to any member of his family residing in the same household. Any person violating the provisions of this Section is guilty of a misdemeanor and, upon conviction, must be fined not less than 100 nor more than 200 or imprisoned for thirty (30) days and, upon conviction for a second offense be fined 200 or imprisoned for thirty (30) days, or both, and for a third and subsequent offenses must be imprisoned for not less than forty-five (45) days nor more than six (6) months. Only convictions which occurred within five (5) years including and immediately preceding the date of the last conviction constitute prior convictions within the meaning of this Section. THE APPLICANT MUST ANSWER THE FOLLOWING QUESTIONS 1. HAVE YOU OWNED A MOTOR VEHICLE REGISTERED IN SOUTH CAROLINA DURING THE LAST TWELVE (12) MONTHS? 2. IF SO, HAS THE TITLE TO THIS MOTOR VEHICLE BEEN TRANSFERRED TO ATHER PERSON? 3. IF SO, LIST NAME OF OTHER PERSON: 4. SINCE THIS MOTOR VEHICLE HAS BEEN DISPOSED OF, HAVE YOU DRIVEN IT OR DO YOU INTEND TO DRIVE IT IN THE FUTURE? 5. THE APPLICANT HEREBY REPRESENTS THAT HE OR SHE HAS READ, OR HAS HAD READ TO THEM, THE LAW PRINTED ABOVE AND HAS RESPONDED TRUTHFULLY TO THE ABOVE QUESTIONS. APPLICANT S SIGNATURE DATE (Mo./Day/Yr.) HOUR * * COVERAGE IS ONLY APPLICABLE WITHIN THE STATE OF SOUTH CAROLINA * * SECTION 14 - EVIDENCE OF INSURANCE AND REQUESTED EFFECTIVE DATE OF COVERAGE This application shall be evidence of temporary insurance subject to the following conditions: 1. The application must be fully completed and duly executed. 2. Coverage under this Evidence of Insurance and Requested Effective Date of Coverage Section is to be effective for a period not to exceed 30 days from the effective date and time. Within such 30 day period coverage will terminate immediately upon: a. the issuance of the policy applied for, b. the issuance of any policy affording similar insurance, or c. the cancellation of the coverages of insurance afforded hereunder in accordance with the rules of the AAIP of SC. 3. A premium charge will be made if the policy is not accepted by the insured. 4. The coverage afforded hereunder shall be subject to all terms and conditions of the Plan and the Policy Form prescribed for use. 5. The Producer of Record must forward this application to the Plan Office no later than two working days after the application is written completed. EFFECTIVE DATE Coverage shall become effective at 12:01 on the day following the date of mailing the application to the Plan as shown by the postmark on the transmittal envelope, or at 12:01 on the future effective date, as follows, whichever is later. In the event there is no U.S. Postmark, coverage will become effective no earlier than 12:01 on the day following receipt in the Plan Office, or on the future effective date, whichever is later. A metered mail postmark, electronic stamp, or other postage service or stamp is not considered a U.S. Postmark. Requested Effective Date and Time: / / / Month Day Year Hour PRODUCER OF RECORD STATEMENT I hereby certify that I am a licensed broker/agent of the State of South Carolina. I have read the AAIP of SC Plan and have explained the provisions to the applicant. I acknowledge that I am acting on behalf of the applicant in submitting this application and have no authority to establish or revise the terms or conditions of coverage. This application includes all required information given to me by the applicant. In the event of cancellation or change to the policy resulting in a reduction of premium, I agree to return the unearned premium to the insured (net of any minimum premium due the company) and also to return to the company unearned compensation for this insurance received by me as required by the Plan. I certify that I have at least one voluntary market for automobile insurance, submitted an application to a voluntary market insurer on behalf of the applicant, and the application has been rejected by a voluntary market insurer. My signature hereon represents certification of the Producer of Record Statement AND I certify this application is submitted pursuant to the effective date provisions contained in the Automobile Insurance Plan of this State. PRODUCER S SIGNATURE DATE (Mo./Day/Yr.) HOUR Page 5 of 6
SECTION 15 - APPLICANT S STATEMENT I, the Applicant, declare and certify that: 1. I have tried and failed to obtain automobile insurance in this state within the preceding 60 days and have been unable to obtain such insurance at rates not exceeding those applicable under the Plan. 2. To the best of my knowledge and belief all statements contained in this application are true and that these statements are offered as an inducement to the Company to issue the policy for which I am applying. 3. I realize that any misleading information or failure to disclose required information will not be considered good faith on my part and will prejudice my application for insurance. 4. I hereby agree to pay all premiums when due. 5. I hereby certify that I do not owe any insurance company for automobile premiums due or contracted. 6. I designate as Producer of Record for this insurance the producer or firm named in this application and I understand he is not acting as an agent of any company for the purposes of this insurance. 7. I duly authorize the undersigned to execute this application on my behalf if the Applicant is not a natural person. 8. I agree that no coverage will be in effect if the premium remittance which accompanies this application is justifiably dishonored by any financial institution. 9. I understand that the premiums shown on this application are estimated premiums. The company reserves the right to adjust the premium either prior to or after the issuance of the policy, whenever applicable. * * IN EVENT SHALL COVERAGE BE EFFECTIVE PRIOR TO THE DATE AND HOUR OF COMPLETION OF THIS APPLICATION * * APPLICANT S SIGNATURE DATE (Mo./Day/Yr.) HOUR TICE TO APPLICANT AND PRODUCER In the event acknowledgement of coverage is not received within 30 days, notify the Plan Office. (Toll Free 866-560-4100) FAIR CREDIT REPORTING ACT TICE In addition to routine verification of information pertinent to the insurance applied for, if the application is by an individual for insurance primarily for personal or family purposes, the company to which it is assigned may have an investigative consumer report made including information bearing on character, general reputation, personal characteristics or mode of living and, upon the individual s written request, will disclose in writing the nature and scope of the investigation requested, if such report is provided. REMARKS Page 6 of 6