ACORD 90 NY (2014/12)

ADDITIONAL GARAGING ADDRESS(ES)

TAX TERRITORY

INDICATE IF MAILING ADDRESS IS GARAGING ADDRESS

CARRIER NAIC CODE

POLICY #:PLAN

PAYMENT PLAN

TO APPLMAIL POLICYTO AGENTMAIL POLICY

AGENCY

DIRECTEXPIRATION DATEEFFECTIVE DATE

APPLICANT'S NAME AND MAILING ADDRESS (Include county & ZIP+4)

ACCT #:

TELEPHONE NUMBER

TAX TERRZIP + 4STATECOUNTYCITYSTREETLOC

ZIP + 4STATECITY

RENTEDOWNEDCURRENT RESIDENCE IS

PREVCURRYRS AT ADDR PREVIOUS STREET ADDRESS (If less than 3 years)

RESIDENCE

NAME:CONTACT

(A/C, No, Ext):PHONE

(A/C, No):FAX

AGENCY

SUBCODE:CODE:

AGENCY CUSTOMER ID:

E-MAILADDRESS:

NEW YORK PERSONAL AUTO APPLICATIONDATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

© 1981-2014 ACORD CORPORATION. All rights reserved.

will be added to the total premium for each vehicle* Motor Vehicle Law Enforcement Fee, as required by New York law,

TOTAL PERVEHICLE * $$$$ESTIMATED TOTAL: $ POLICY FEE: $

$$$$%

$

$

$

OPTIONSDEDUCTIBLELIMIT APPLIES TOLIMITDESCRIPTIONCODE

$FG $

FG $

FG $

FG $ $ $ $COLLISION DED

$ / $ / $ / $ /TRANS EXP / RENTAL RE $ $ $ $

TOWING & LABOR $ $ $ $ $ $ $ $

N / A N / A N / A N / A$ $ $ $ACV UNLESS AMOUNT STATED

$ $ $ $

$ $ $ $

$ EA PERSON $ EA ACCIDENT

$ EA PERSON $ EA ACCIDENT

$ $ $ $$ EA PERSONMEDICAL PAYMENTS

PROPERTY DAMAGE LIABILITY $ EA ACCIDENT $ $ $ $

$ $ $ $EA ACCIDENT$EA PERSON$BODILY INJURY LIABILITY

SINGLE LIMIT LIABILITY (CSL) $ EA ACCIDENT $ $ $ $

COVERAGES LIMITS OF LIABILITY VEHICLE # VEHICLE # VEHICLE # VEHICLE #

COVERAGES / PREMIUMS

SUPPLEMENTARY UM/UIM (SUM)

STATUTORY UM BI

$ $ $ $SUPPLEMENTAL SPOUSAL LIABILITY NOT INCLUDEDINCLUDED

$

BENDEATH

$EXPOTHER

$LOSSWORK

$$

NAMED INSURED AND RELATIVESNAMED INSURED ONLY

Y / N

DEDUCTIBLE$$

OBEL

PERSONAL INJURY PROTECTIONADDITIONALMED EXP ELIMINATION

WORK LOSS COORDINATION

PERSONAL INJURY PROTECTION

$

$

$

$

$

$

$

$

$

$

$

$

$ $ $ $GF

$ GF

$ GF

$ GF

$COMPREHENSIVE / OTC DED

STATEREG

VEH

LOC

SYMCOLL

OTC SYMCOMP

CLASS DEVICESANTI-THEFT CREDITS AND

SURCHARGESSEAT BELT DRV/BOTHPASSIVE AIRBAG

VEHANTI-LOCKBRAKES 2/4 CLASS DEVICES

ANTI-THEFT CREDITS ANDSURCHARGESSEAT BELT DRV/BOTH

PASSIVE AIRBAGVEH

ANTI-LOCKBRAKES 2/4

TOTAL NUMBER OF VEHICLES IN HOUSEHOLD:VEHICLE DESCRIPTION / USE

DRV #REG TO

BODY TYPEMODELYEAR MAKE VIN HP/CCDATE

LEASEDDATE

PURCHNEW/USEDVEH

AGE GRP READING MILEAGECOST NEWSYMBOL

TERRODOMETER ANNUAL DRIVER USE % (Each veh must equal 100%)MILE 1 WAY

WK/SCHL# DAYSWEEK

# WKSMONTH USAGE

PER-FORM

MULTI-CAR

CARPOOL

GARCODE

GOVERNDRIVER

Page 1 of 4

ACORD 90 NY (2014/12)

NAME AS IT APPEARS ON REGISTRATIONVEH #NAME AS IT APPEARS ON REGISTRATIONVEH #

WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY ANDREGISTERED TO THE APPLICANT?

1.

Y / N

ASSIGNED RISK?

PRIOR COVERAGEPRIOR CARRIER # OF YEARS

PRIOR POLICY NUMBER

WITH COMPANY

PRIOR PRODUCER EXPIRATION DATE

OWNER REGISTRANT

LIENHOLDERLOSS PAYEE

ADDL INS

LOAN NUMBER

VEH #:NAME AND ADDRESS

OWNER REGISTRANT

LIENHOLDERLOSS PAYEE

ADDL INS

LOAN NUMBER

NAME AND ADDRESS VEH #:

ADDITIONAL INTEREST

OR BEEN CONVICTED OF A MOVING VIOLATION WITHIN THE LAST 39 MONTHS?HAS ANY DRIVER SHOWN ABOVE HAD AN ACCIDENT, REGARDLESS OF FAULT,

Attach ACORD 99, Accidents / Convictions Schedule, if more space is requiredACCIDENTS / CONVICTIONS (Note: Your driving record is verified with the state motor vehicle department and other insurers)

IF YES, INDICATE BELOW. ALSO INCLUDE COMPREHENSIVE INSURANCE LOSSES.Y / N

Y / NAMOUNT OFBI OR DEATHPLACE OFDATE OFDRV

# ACCIDENT / CONVICTION DESCRIPTION OF ACCIDENT OR CONVICTION ACCIDENT / CONVICTION PROPERTY DAMAGE

4.

$

COSTDESCRIPTION

$

DRV # DRV #COSTDESCRIPTION

ANY OTHER LOSSES NOT SHOWN IN THE ACCIDENTS / CONVICTIONS SECTION THAT WERE INCURRED DURING THE TIME PERIOD SPECIFIED INTHAT SECTION?

POLICY NUMBERNAIC #CARRIERNAMED INSURED MODELMAKEYEAR

5. ANY OTHER AUTO INSURANCE IN HOUSEHOLD? (Include any provided by employer)

VEH #VEH # DESCRIPTIONDESCRIPTION

3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass)

VEH #VEH #

$

COSTDESCRIPTION

$

COSTDESCRIPTION

2. ANY CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans / pickups)

Y / NEXPLAIN ALL "YES" RESPONSES

GENERAL INFORMATION

EMPLOYMENT INFORMATION (* If less than 2 years, provide name of previous employer and previous occupation under Remarks)ADDRESS OF EMPLOYMENT WORK PHONE NUMBER * YEARS W/

CURR EMPLYEARS W/

PREV EMPL(State nature of business if self-employed)APPLICANT'S EMPLOYER

CO-APPLICANT'S EMPLOYER(State nature of business if self-employed) PREV EMPL

YEARS W/CURR EMPL* YEARS W/WORK PHONE NUMBERADDRESS OF EMPLOYMENT

STATELIC

DATE LICACC PREVCSE DATE DRIVERS LICENSE # SOCIAL SECURITY #

STDT>100

GOODSTDT

DRVTRAIN# OCCUPATION

REL TOAPPLIC

MARSTATLAST NAMEMIDDLE NAMEFIRST NAME

NAME (AS IT APPEARS ON LICENSE)DATE OF BIRTH# SEX

RESIDENT & DRIVER INFORMATION [List all residents & dependents (licensed or not) and regular operators]

AGENCY CUSTOMER ID:

Page 2 of 4

LENDER'S LOSS PAYABLE

LENDER'S LOSS PAYABLE

ACORD 90 NY (2014/12)

X

Page 3 of 4

STATE SUPPLEMENT

BILL OF SALE

PHOTOGRAPH

MOTOR VEHICLE REPORT

MEDICAL STATEMENT

ANTI-THEFT DEVICE CERTIFICATE

GOOD STUDENT CERTIFICATE

DRIVER TRAINING CERTIFICATE

YOUNG DRIVER QUESTIONNAIRE

REMARKS / ATTACHMENTS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

PERSON COVEREDNAME OF PLANPERSON COVEREDNAME OF PLAN

ANY APPLICANT COVERED BY A WAGE CONTINUATION PLAN?18.

DESCRIPTION OF SPECIAL EQUIPMENT IN VEHICLEDRV #

ANY DRIVER HAVE A PHYSICAL IMPAIRMENT THAT WOULD AFFECT THE ABILITY TO DRIVE?9.

EXPLANATIONDRV #

ANY DRIVER UNDERGOING A COURSE OF MEDICAL TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT THAT WOULD AFFECT THE ABILITY TO DRIVE?10.

FILING DATEREASON FOR FILINGDRV #

ANY FINANCIAL RESPONSIBILITY FILING?11.

HAS INSURANCE BEEN TRANSFERRED WITHIN THE AGENCY?12.

REASON DECLINED, CANCELLED, OR NON-RENEWEDDRV #

ANY COVERAGE DECLINED, CANCELLED, OR NON-RENEWED DURING THE LAST THREE (3) YEARS?13.

IS THIS BROKERED BUSINESS TO THE AGENT?14.

HAS AGENT INSPECTED VEHICLE?15.

EXPLANATIONDRV #

16. HAS ANY APPLICANT OR DRIVER HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY, JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?

EXPLANATIONDRV #

HAS ANY NAMED INSURED DRIVEN WITHOUT LIABILITY INSURANCE DURING ANY PART OF THE LAST SIX (6) MONTHS?17.

TYPE OF INSURANCETYPE OF INSURANCE POLICY NUMBERPOLICY NUMBER

6. ANY OTHER INSURANCE WITH THIS COMPANY?

DATEREINSTATEMENTEXPLANATION

End Date:Start Date:

SUSPENSION PERIODDRV #

8. ANY DRIVERS LICENSE BEEN SUSPENDED / REVOKED?

VEH AT BASE (Y / N)BASE LOCATIONRANKBRANCHDRV #

7. ANY HOUSEHOLD MEMBER IN MILITARY SERVICE?

Y / NEXPLAIN ALL "YES" RESPONSES

GENERAL INFORMATION (continued)AGENCY CUSTOMER ID:

IF YOU HAVE PURCHASED RENTAL VEHICLE REIMBURSEMENT COVERAGE AND YOUR VEHICLE IS DAMAGED AND ISTEMPORARILY OUT OF SERVICE DUE TO A LOSS COVERED UNDER YOUR POLICY, NEW YORK LAW STATES THAT YOU HAVETHE RIGHT TO UTILIZE ANY RENTAL VEHICLE COMPANY, RENTAL VEHICLE LOCATION OR A PARTICULAR CONCERN OF YOURCHOICE.

REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

ACORD 90 NY (2014/12) Page 4 of 4

I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEFTHAT THE SIGNATURE OF THE APPLICANT IS THE PERSONALSIGNATURE OF THE APPLICANT.

PRODUCER'S STATEMENT: HOW LONG HAVEYOU KNOWN THEAPPLICANT?

THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BYWRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE.

IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:

COVERAGE IS NOT BOUND

NOON

12:01 AM

THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICYCONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY,THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THECOMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY.

THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THISINSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) INCURRENT USE BY THE COMPANY.TIME

EXPIRATION DATEEFFECTIVE DATE

INSURANCE BINDER

AGENCY CUSTOMER ID:

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES ANAPPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALSFOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES NOT TO EXCEED FIVETHOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBERAPPLICANT'S SIGNATURE DATE

APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THEINFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THISINFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING.IN ADDITION, IF THE AUTO PLAN OR COMPANY DESIGNATED IN THIS APPLICATION IS NON-STANDARD, I CERTIFY THAT IUNDERSTAND THE RATES FOR THIS COVERAGE ARE HIGHER THAN NORMAL, AND THAT THEY ARE ACCEPTABLE TO ME AS IHAVE BEEN UNABLE TO OBTAIN COVERAGE DESIRED THROUGH THE NORMAL INSURANCE MARKET.

I HAVE HAD STATUTORY UNINSURED MOTORISTS AND SUPPLEMENTARY UNINSURED / UNDERINSURED MOTORISTS (SUM)COVERAGE INCLUDING THE AVAILABLE OPTIONS AND LIMITS EXPLAINED TO ME. I UNDERSTAND THAT THE COVERAGESELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE RENEWALS, CONTINUATIONS AND CHANGES INMY POLICY UNLESS I NOTIFY YOU OTHERWISE IN WRITING.

BINDER / SIGNATURE

COPY OF ACORD 38 NY, NOTICE OF INSURANCE INFORMATION PRACTICES HAS BEEN GIVEN TO THE APPLICANT.

A CREDIT REPORT OR OTHER INVESTIGATIVE REPORT ABOUT YOU MAY BE REQUESTED IN CONNECTION WITH THISAPPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. IN CONNECTION WITH THIS INSURANCE,WE MAY REVIEW YOUR CREDIT REPORT OR OBTAIN OR USE A CREDIT-BASED INSURANCE SCORE BASED ON INFORMATIONCONTAINED IN THAT REPORT. AN INSURANCE SCORE USES INFORMATION FROM YOUR CREDIT REPORT TO HELP PREDICTHOW OFTEN YOU ARE LIKELY TO FILE CLAIMS AND HOW EXPENSIVE THOSE CLAIMS WILL BE. TYPICAL ITEMS FROM A CREDITREPORT THAT COULD AFFECT A SCORE INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING: PAYMENT HISTORY, NUMBEROF REVOLVING ACCOUNTS, NUMBER OF NEW ACCOUNTS, THE PRESENCE OF COLLECTION ACCOUNTS, BANKRUPTCIES ANDFORECLOSURES. THE INFORMATION USED TO DEVELOP THE INSURANCE SCORE COMES FROM:Insert Name of Consumer Reporting Agency:

YOU HAVE THE RIGHT TO SEE PERSONAL INFORMATION COLLECTED ABOUT YOU, AND YOU HAVE THE RIGHT TO CORRECTANY INFORMATION WHICH MAY BE WRONG. IF YOU ARE INTERESTED IN OBTAINING A DESCRIPTION OF OUR INFORMATIONPRACTICES, AND YOUR RIGHTS REGARDING INFORMATION WE COLLECT, ASK YOUR AGENT, OR, IF YOU HAVE BEEN ISSUED APOLICY, PLEASE WRITE US AT THE ADDRESS PROVIDED WITH YOUR POLICY.