Policy CLEAR SPRING PROPERTY & CASUALTY COMPANY State Policy Number
Application
227 West Monroe, Suite 3950, Chicago, IL 60606 (Herein Company)
Serviced by: Amigo MGA, LLC, PO Box 85218,HallandaleBeach,FL33008(1-855-226-4466) GA GAB20006800
1a. Effective Date and Time 1b. Binding Date and Time 2. Term 3. Application 4. Down Payment 5. Agent
01/27/2021 10:44 PM ET 6 Month $175.65 53536
Applicant's Name: Work Phone Number: Cell Phone Number: Home Phone Number: Agent's Phone Number:
Cassandra Acosta (470)263-1060 (470)263-1060 (770)674-8951
Applicant's Garaging Address: Applicant's Mailing Address: Agent's Name, Mailing Address and Phone Number:
3072 WASHINGTON RD 3072 WASHINGTON RD B3 Ensurify Insurance Agency, Inc.
Atlanta, GA 30344-0000 Atlanta, GA 30344-0000 222 THIRD ST STE. 1320
CAMBRIDGE, MA 02142-0000
(770)674-8951
A driver is any person who regularly has custody or control of an insured vehicle or who is a family member,14 years or older, whether licensed or unlicensed and any otherperson who lives in the applicant's household.
WARNING: YOUMUSTLISTALLDRIVERSANDADDRESSES; useanextrasheetifnecessary. Failure to list all drivers andaddressesmayresultindenialofa claim. Toexcludeadriver, attachdriverexclusion form.
Drv. Name Relation DOB Sex MS SR22 Driver's License No. Occupation Class Pts.
1 Cassandra Acosta Policyholder 06/04/1983 F S No 058228298 SCFS37
Complete if the applicant, drivers or anyone who drives the vehicle(s) has been involved in a motor vehicle accident or has received motor vehicle violations during the 36-month period immediately preceding the
date of this application.
Drv. Violation Type Date Drv. Violation Type Date Drv. Violation Type Date
Complete for each owned vehicle applying for coverage.
Veh. Year Make - Model - Body Type Vehicle Identification Number Symbol Miles Use Zip Code Territory
1 1999 Ford TAURUS SE/TAURUS SE SPORT Passenger 4 Door 1FAFP53U7XA331380 08, 08 Commute 30344
Veh. Lienholder Name Address, City, State and Zip Code
Premiums shown are estimates. The actual Premium will be determined in accordance with approved rates and rating plans and other consumer reporting information.
Vehicle # 1 Vehicle # Vehicle # Vehicle #
Limit Premium Limit Premium Limit Premium Limit Premium
Bodily Injury $25,000/$50,000 $562.28
Property Damage $25,000 $251.37
Medical Coverage $0 N/A
Uninsured Property Damage $0 N/A
Uninsured Bodily Injury Coverage N/A
Rejected
Comprehensive Up To 40,000 (MSRP) N/A
Collision Up To 40,000 (MSRP) N/A
RENTAL REIMBURSEMENT
TOWING Not Covered
SPECIAL EQUIPMENT
Total Total Total Total
Vehicle 1 $813.65 Vehicle Vehicle Vehicle
Underwriting
SR22 Fee $0.00 $15.00 Policy Fee $25.00
Fee
Premium Total $853.65
Down Payment $175.65
PolicyApplicationStateGACompany300Rev20190221 Page 1-3 POLICY APPLICATION
Policy CLEAR SPRING PROPERTY & CASUALTY COMPANY State Policy Number
Application
227 West Monroe, Suite 3950, Chicago, IL 60606 (Herein Company)
Serviced by: Amigo MGA, LLC, PO Box 85218,HallandaleBeach,FL33008(1-855-226-4466) GA GAB20006800
12. Questions - Please answer the following questions with a Yes (Y) or a No (N). Answers
No
Q-1 Would you like to be set up on automated monthly installments?
No
Q-2 Do you own your own home?
Are all residents of the household 14 years or older (licensed or unlicensed) and all regular operators including those away at school or military listed Yes
Q-3
or excluded?
No
Q-4 Are any listed driver's license currently suspended, revoked or cancelled?
Is any listed driver currently being treated, or have been in the past 3 years, for a physical or mental condition (epilepsy, heart condition, etc) that may No
Q-5
affect their ability to safely operate a vehicle?
No
Q-6 Are any vehicles equipped with modification for persons with special needs or loss of limb?
No
Q-7 Will any vehicle be used for business, farm, delivery (newspapers, pizza, groceries, etc.) transportation of people or goods for a fee?
No
Q-8 Does any vehicle have a salvaged title?
No
Q-9 Has any vehicle been modified or has damage that is considered a hazard - bald tires, broken glass, no tailgate etc.?
No
Q-10 Are any of the listed vehicles frequently driven by, or regularly made available to, individuals other than the listed drivers?
Are any listed vehicles used for racing, police or emergency response, taxi service, rental, driver training, off road use, transport of explosives/ No
Q-11
flammables, snowplowing or as a residence?
No
Q-12 Do any listed vehicles have more or less than 4 wheels, have a load capacity of over 3/4 ton or are equipped to carry more than 8 passengers?
No
Q-13 Are there any vehicles listed making regular or frequent trips beyond a fifty (50) mile radius?
No
Q-14 Are there any drivers listed on the application with a Driving Under the Influence of Alcohol (DUIA) or Driving Under the Influence of Drugs (DUID)?
No
Q-15 Are any listed vehicles titled or owned by someone other than the named insured or spouse?
No
Q-16 Are there other vehicles in your household not listed on this application? If so, provide vehicle, driver, and insurance carrier information.
IMPORTANT! Please Read Carefully!
APPLICANT SIGNATURE SECTION
I understand that personal information about me may be collected from persons other than me or covered drivers. Such information as well as other personal and
privileged information collected by the Company or my agent may in certain circumstances be disclosed to third parties as required by the Company in the normal
course of business with this authorization. I have the right to review my personal information in the Company files and can request correction of any inaccuracies.
A more detailed description of your rights and our practices regarding such information is available upon request.
I'm applying to the Company for an insurance policy based on the statements contained in this application and I understand that this application is
thereby made a part of my policy. I agree that such policy shall be null and void if such information is false, misleading, or would materially affect
acceptance of the risk by the Company. I also agree that if a bank does not honor my premium remittance, no coverage will be considered bound, and
coverage will be considered null and void. Any person who knowingly and with intent to defraud any insurance company, or any other person, files an
application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
I understand that the coverage selection and limit choices indicated here, or in any endorsement will apply to all future policy renewals, continuations and changes
unless I notify the Company otherwise in writing.
Premiums shown are estimates. The actual Premium will be determined in accordance with approved rates and rating plans and other consumer
reporting information.
13a. Insured's Signature 13b. Insured's Date and Time Signed
Cassandra Acosta 2021-01-27 22:46:40 (UTC-05:00)
AGENT SIGNATURE SECTION
I certify that all information herein is correct to the best of my knowledge, that this form was completed by the applicant and/or that the information was provided
by the applicant and has been read and signed by the applicant. A copy has been given to the applicant and that I have retained a duplicate signed copy.
14a. Agent's Signature 14b. Agent's Date and Time Signed
PolicyApplicationStateGACompany300Rev20190221 Page 2-3 POLICY APPLICATION
Policy CLEAR SPRING PROPERTY & CASUALTY COMPANY State Policy Number
GAB20006800
227 West Monroe, Suite 3950, Chicago, IL 60606 (Herein Company)
Serviced by: Amigo MGA, LLC, PO Box 85218, Hallandale Beach, FL 33008 (1-855-226-4466) GA
WARNING! Read These Endorsements Carefully!
PUNITIVE AND EXEMPLARY DAMAGE EXCLUSION - This applies ONLY IF YOU SELECT this exclusion.
In consideration of a reduced premium, it is understood and agreed that the insurance afforded by this Part I – Liability to Others shall not apply to the payment of
punitive or exemplary damages as the result of an accident. This includes any accidents that occur while any auto(s) described in the policy or any auto(s) being
used or operated by any person or entity that is entitled to coverages under this policy. All other provisions apply.
I hereby elect the Punitive & Exemplary Damage Exclusion.
15a. 15b.
Cassandra Acosta 2021-01-27 22:46:40 (UTC-05:00)
EXCLUSION OF NAMED DRIVER AND PARTIAL REJECTION OF COVERAGES
This acknowledgement and rejection are applicable to all renewals issued by us or any affiliated insurer. However, we must provide a notice with each renewal
as follows: "This policy contains a named driver exclusion."
You agree that none of the insurance coverage afforded by this policy shall apply while
(The Excluded Driver(s))
is(are) operating your covered auto or any other motor vehicle. You further agree that this endorsement will also serve as a rejection of Uninsured/Underinsured
Motorist Coverage and Personal Injury Protection Coverage while your covered auto or any other motor vehicle is operated by the excluded driver.
16a. Insured's Signature 16b. Insured's Date and Time Signed
STATEMENT OF NON-BUSINESS USE / NON COMMERCIAL USE
I HEREBY CERTIFY THAT ANY CAR I OWN OR ANY REPLACEMENT VEHICLE ARE NOT USED IN ANY BUSINESS OR COMMERCIAL USE.
Or any additional replacement vehicle(s) is (are) not used for any business or commercial use. I also certify that if at a later date the vehicle(s) is (are) to be used
for business or commercial use that I will notify my agent prior to using the vehicle(s) for any type of business or commercial use. I understand that if I fail to notify
my agent of such changes, that a claim may be denied for misrepresentation.
Or any additional replacement vehicle(s) is (are) not used for any business or commercial use. I also certify that if at a later date the vehicle(s) is (are) to be used
for business or commercial use that I will notify my agent prior to using the vehicle(s) for any type of business or commercial use. I understand that if I fail to notify
my agent of such changes, that a claim may be denied for misrepresentation.
17a. Insured's Signature 17b. Insured's Date and Time Signed
Cassandra Acosta 2021-01-27 22:46:40 (UTC-05:00)
NOTICE OF REJECTION OF UNINSURED MOTORIST/SELECTION OF LOWER COVERAGE LIMITS
YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING
UNINSURED MOTORIST LIMITS LESS THAN YOUR BODILY LIABILITY LIMITS WHEN YOU SIGN THIS FORM.
PLEASE READ CAREFULLY
Uninsured Motorist Coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehicles because of bodily
injury or death resulting there from. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations
and conditions in the policy. The law required us to issue your policy with Uninsured Motorist Coverage with limits equal to those provided in your Bodily Injury
Liability policy, unless you reject Uninsured Motorist Coverage in writing or select lower coverage limits (reference Georgia Statute 33-7-11). If you keep Uninsured
Motorist coverage, there are two options available: 1) Added on to At Fault Liability Limits; and, 2) Reduced by At Fault Liability Limits. For more information about
the options for Uninsured Motorist coverage, please see your policy.
A. I wish to completely REJECT Uninsured Motorist Coverage and agree that such coverage be deleted from this policy.
Cassandra Acosta
B. I wish to maintain Uninsured Motorist Coverage for Bodily Injury to the following limits: $ 25,000 / $ 50,000 / $25,000 each person/each
accident (split limits) for the following Uninsured Motorist Coverage (select one):
I SELECT Uninsured Motorist Coverage - Added on to At-Fault Liability Limits (Premium $ )
I SELECT Uninsured Motorist Coverage - Reduced by At-Fault Liability Limits (Premium $ )
C. I wish to REJECT Uninsured Motorist Coverage-Added on to At-Fault Liability
Limits (not required if coverage was rejected in part A. above).
I have fully read and understand all information provided on this application for coverage. I hereby attest this to be a full, complete and truthful detailing of all related information for all
drivers and vehicles for which I am seeking coverage under this policy.
18a. Insured's Signature 18b. Insured's Date and Time Signed
Cassandra Acosta 2021-01-27 22:46:40 (UTC-05:00)
PolicyApplicationStateGACompany300Rev20190221 Page 3-3 POLICY APPLICATION
Electronic CLEAR SPRING PROPERTY & CASUALTY State Policy Number
GAB20006800
Signature Adoption COMPANY GA
227 West Monroe, Suite 3950, Chicago, IL 60606 (Herein Company)
Serviced by: Amigo MGA, LLC, PO Box 85218, Hallandale Beach, FL 33008 (1-855-226-4466)
1.Effective Date: 2.Term: 3.Agent Code: 4.Application Number: 5.Insured Name:
01/27/2021 6 Month 53536 GAB20006800 Cassandra Acosta
***NOTICE TO AGENT ABOUT ELECTRONIC SIGNATURES***
Under penalty of perjury, I hereby swear, and would so testify that I have provided the
applicant the computer mouse for the applicant to click his electronic signature on this
application and that I have provided the applicant with the opportunity to read the entire
application including but not limited to all disclosures, selections/rejections and have also
informed the applicant verbally as to all coverages purchased and those coverages that
the application has rejected and/or has not purchased.
6a. Agent’s Signature 6b. Agent’s Date Signed
***NOTICE TO APPLICANT ABOUT ELECTRONIC SIGNATURES***
You acknowledge and agree that by typing your name in the designated box below and
by clicking ‘Adopt and Sign’, you are electronically signing this application, which will
have the same legal effect as the execution of this document by a written signature and
shall be valid evidence of your intent and agreement to be bound by its terms.
I understand that my name already appears in the signature box below because I chose
to electronically sign this application.
7a. Insured’s Signature 7b. Insured’s Date Signed
Cassandra Acosta 2021-01-27 22:46:40 (UTC-05:00)
ElectronicSignatureAdoptionStateGACompany300Rev_20190528 Page 1-1 ELECTRONIC SIGNATURE ADOPTION
