t#JUUFGàMMFO4JFEFO'30'SBHFCPHFONJUEFN;VTBU[GSBHFCPHFOBVT VOETFOEFOJIOVOUFSTDISJFCFOBOVOT[VSàDL t%FO46/3*4&(3061'SBHFCPHFOVOUFSTDISFJCFO4JFCJUUFOVS VOETFOEFOJIOVOBVTHFGàMMUBOVOT[VSàDL t%JF1SÊNJFO3FDIOVOHFSIBMUFO4JFEJSFLUWPN7FSTJDIFSFS[VTBNNFONJU EFN0SJHJOBMEFS1PMJDF&JOF,PQJFEFS1PMJDFFSIBMUFO4JFCFSFJUTWPSBC BMTQEG%BUFJQFS&.BJM#JUUFUFJMFO4JFVOT*ISF&.BJM"ESFTTFNJU t6OTFSF(FCàISCFUSÊHUûEJF4JFCJUUFCFJ"OUSBHTUFMMVOHBVGVOTFS ,POUPFJO[BIMFO
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#JUUF CFEFOLFO 4JF EBTT KF OBDI #VOEFTTUBBU [XJTDIFO VOE EFS EPSU GBISFOEFO 'BIS[FVHF HBS OJDIU PEFS OVS VO[VSFJDIFOE WFSTJDIFSU TJOE
INFORMATIONEN
t#JUUFàCFSXFJTFO4JFEJF7FSTJDIFSVOHTQSÊNJFBVGVOTFS,POUPCFJEFS)ZQP7FSFJOTCBOL *#"/%&48*'5#*$):7&%&..
t'àS;BIMVOHFONJU.BTUFSPEFS7*4"$BSEGàMMFO4JFCJUUFEBTVOUFOTUFIFOEF'PSNVMBSGàS,SFEJULBSUFO[BIMVOH BVTVOETFOEFOFTQFS1PTUPEFS5FMFGBY(nicht per E-Mail)BOVOTFS#àSP[VSàDL
t8FJUFSF3FJTF;VTBU[WFSTJDIFSVOHFOFSIBMUFO4JFFCFOGBMMTàCFSVOT #JUUFGPSEFSO4JFFOUTQSFDIFOEF6OUFSMBHFOCFJ#FEBSGBO
Der Versicherungsschutz:
%JF %FDLVOHTTVNNF CFUSÊHU 64 GàS 1FSTPOFO TDIÊEFO VOE 64 GàS 4BDITDIÊEFO &CFOGBMMT TJOE NJOEFTUFOT 64 )FJMLPTUFO GàS BNCVMBOUF #FIBOE MVOH GàS 'BISFS VOE #FJGBISFS JO *ISFN 'BIS[FVH TPXJF 64 PEFS 64 6OJOTVSFE .PUPSJTUT FJOHF TDIMPTTFO %JFTF 4VNNFO LÚOOFO KF OBDI #VOEFTTUBBU JO EFN*ISF3FJTFCFHJOOUWBSJJFSFO&JOF%FDLVOHGàS6OGÊMMF NJU OJDIU WFSTJDIFSUFO 6OGBMMHFHOFSO 6OJOTVSFE .PUPSJTUT JTUJOEFS)BGUQøJDIUEFDLVOHFOUIBMUFO
;VTÊU[MJDI [VS )BGUQøJDIUWFSTJDIFSVOH XJSE GàS 1,8 FJOF ,BTLPWFSTJDIFSVOH 5FJM VOE 7PMMLBTLP HFXÊISU #BTJT JTU EFS ;FJUXFSU EFT 'BIS[FVHT *N 4DIBEFOGBMM USÊHU EFS7FSTJ DIFSFSEJF3FQBSBUVSLPTUFOCJTNBY[VN;FJUXFSUCFJ5PUBM TDIBEFO XJSE EFS ;FJUXFSU FSTUBUUFU %JF 'BIS[FVHF EàSGFO CFJ "CTDIMVTT EFS7FSTJDIFSVOH GàS7PMMLBTLP OJDIU ÊMUFS BMT +BISF TFJOBei Campingfahrzeugen ist Teil/Vollkasko nicht möglich.
&THFMUFOHSVOETÊU[MJDIEJF#FEJOHVOHFOEFTBNFSJLBOJTDIFO 7FSTJDIFSFST4PTJOE[#(MBTCSVDITDIÊEFOOJDIUWFSTJDIFSU 4DIÊEFONJU)BBSXJMETJOEEBHFHFOàCFSEJF7PMMLBTLPWFS TJDIFSVOH FJOHFTDIMPTTFO %JF 4FMCTUCFUFJMJHVOH CFUSÊHU 64CFJEFS5FJMLBTLPVOE64CFJEFS7PMMLBTLPWFS TJDIFSVOH
'àSEFO)JOVOE3àDLUSBOTQPSUFNQGFIMFOXJSEFO"CTDIMVTT FJOFS5SBOTQPSUWFSTJDIFSVOH/ÊIFSF*OGPTFSGSBHFO4JFCJUUF CFJ*ISFN4QFEJUFVS
Wer wird versichert:
(SVOETÊU[MJDITJOEOVSEJFJOEFS1PMJDFHFOBOOUFO1FSTPOFO WFSTJDIFSU%FTIBMCTJOEJN"OUSBHEJFJO'SBHFLPNNFOEFO 'BISFSNJUJISFO(FCVSUTEBUFOBVG[VGàISFO(FOFSFMMTJOEBMMF 1FSTPOFOJN"MUFS[XJTDIFOVOE+BISFOEJFJN#FTJU[ FJOFS HàMUJHFO 'BISFSMBVCOJT TJOE WFSTJDIFSCBS 4PMMUF EBT -FCFOTKBISàCFSTDISJUUFOTFJONVTTFJOvNFEJDBMSFQPSUi WPN "S[U EJF 'BISUàDIUJHLFJU CFTUÊUJHFO %BT 'PSNVMBS GPS EFSO4JFCJUUFCFJVOTBO
Was wird versichert:
7FSTJDIFSUXFSEFOHSVOETÊU[MJDIOVSEJFFJHFOFO'BIS[FVHF "OUSÊHFGàS4QPSUXBHFOXJF1PSTDIFPEFSBOEFSFIPDIXFS UJHF 'BIS[FVHF XFSEFO EVSDI EJF 7FSTJDIFSFS HFQSàGU VOE LÚOOFO HHG BCHFMFIOU XFSEFO 4JOE 'BIS[FVHF ÊMUFS BMT +BISFCFOÚUJHFOEJF7FSTJDIFSFSVOCFEJOHUEFO[VTÊU[MJ DIFOvNFDIBOJDBMSFQPSUi#JUUFCFJVOTBOGPSEFSO
#FJ $BNQFSO CSBVDIFO XJS FJO 'PUP *OOFO VOE "VFOCF SFJDI ;VN $BNQFS VNHFCBVUF -,8 XFSEFO OJDIU BOHF OPNNFO
Versicherungsdauer:
%JF1PMJDFXJSEHFOFSFMMGàS+BISWPN7FSTJDIFSFSBVTHFTUFMMU VOE CFSFDIOFU 4JF WFSMÊOHFSU TJDI BVUPNBUJTDI GBMMT LFJOF ,àOEJHVOHWPO*IOFOFSGPMHU'BMMT4JFFJOFLàS[FSF-BVG[FJU CFOÚUJHFOTFOEFO4JFFJOF,àOEJHVOHEJSFLUBOEFO7FSTJ DIFSFSPEFSBOVOT8JSLÚOOFO*ISF,àOEJHVOHXFJUFSMFJUFO 4JFFSIBMUFOEBOOFJOFO4DIFDLàCFSEJF(VUTDISJGU%JF.JOJ NVN-BVG[FJUCFUSÊHUJNNFS.POBUF Prämien:
%JF 1SÊNJF XJSE *IOFO EJSFLU WPN 7FSTJDIFSFS CFSFDIOFU XFOOEJF1PMJDFFSTUFMMUXJSE*N%VSDITDIOJUUCFUSÊHUTJF[XJ TDIFO64VOE64KÊISMJDI OVS)BGUQøJDIU*ISF 4DIBEFOGSFJIFJUTSBCBUUFXFSEFOOJDIUBOHFSFDIOFU8JSFSIF CFOFJOF(FCàISWPOû;BIMFO4JFEJFTFCJUUFBVGVOTFS ,POUPCFJ )ZQP7FSFJOTCBOL(SBTLFMMFS)BNCVSH *#"/%& #*$48*'5$PEF):7&%&.. "MUFSOBUJWLÚOOFO4JFVOTFSFOBDIGPMHFOEF,SFEJULBSUFOBV UPSJTJFSVOHWFSXFOEFO Antrag:
#JUUF TFOEFO 4JF EFO "OUSBH BVTHFGàMMU VOE VOUFSTDISJFCFO [V VOT [VSàDL %JF CFSFDIUJHUFO 'BISFS LÚOOFO &IFHBUUFO VOE,JOEFS àCFS+BISFTFJO'àMMFO4JFEFO"OUSBHTFIS TPSHGÊMUJHBVT#FOVU[FO4JFOVSHSPF%SVDLCVDITUBCFOVOE TDISFJCFO 4JF 6NMBVUF XJF [# BMT "& 4PMMUFO 4JF LFJOFO JOUFSOBUJPOBMFO 'àISFSTDIFJO CFTJU[FO USBHFO 4JF CJUUF EJF /VNNFS*ISFTOBUJPOBMFO'àISFSTDIFJOTFJO
Police:
/BDIEFN 4JF VOT EJF BVTHFGàMMUFO "OUSÊHF FJOHFSFJDIU IB CFOEBVFSUFTDB5BHFCJTXJS*IOFOXFJUFSF'PSNVMBSF [VS6OUFSTDISJGU[VTFOEFOEJFXJSWPOVOTFSFS"HFOUVSFSIBM UFO(MFJDI[FJUJHXJSEEBOOEBTv1SPQPTBMiHFTDIJDLUBVTEFN EJF1SÊNJF[VFSTFIFOJTU%BT"VTTUFMMFOEFSFOEHàMUJHFO1P MJDFXJSEEBOOFSOFVUFJOQBBS5BHFEBVFSO#JUUFCFSàDLTJDI UJHFO4JFEJFTF8BSUF[FJU&JOF64"OTDISJGUJTUIJMGSFJDIBCFS OJDIU[XJOHFOEFSGPSEFSMJDI Schäden: 6NLFJOF'SJTUFO[VWFSTÊVNFONFMEFO4JFCJUUFEFO4DIB EFOBN4DIBEFOUBHEFN$MBJN"EKVTUFSVOUFSEFSJOEFS1P MJDF BOHFHFCFOFO5FMFGPOOVNNFS "MMF 4DIBEFOVOUFSMBHFO NàTTFOJOFOHMJTDIFS4QSBDIFBCHFGBTTUTFJO%JF4DIBEFO BCXJDLMVOH XJSE EJSFLU WPN7FSTJDIFSFS JO EFO 64" WPSHF OPNNFO
4PMMUFEJF4DIBEFONFMEVOHOJDIUJOOFSIBMCWPO4UVOEFO FSGPMHFOLBOOEFS7FSTJDIFSVOHTTDIVU[LPNQMFUUFOUGBMMFO Fahrzeugkauf in den USA:
%JF1PMJDFLBOOFSTUCFBOUSBHUXFSEFOXFOOBMMF%BUFOEFT 'BIS[FVHTWPSMJFHFO
Wichtig:
Es wird keine Police erstellt bei Reisebeginn in:
Kanada, Alaska, Idaho, Indiana, Kansas, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Tennessee, Vermont, West Virginia, Wyoming, Wisconsin.
Der angebotene Versicherungsschutz gilt nicht in Mexico!
Grundsätzlich obliegt die letzte Entscheidung, ob die Police erstellt oder der Antrag abgelehnt wird, dem Versicherer in USA.
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Coverage to be effective: GSPN 7FSTJDIFSVOHTCFHJOO %BZ.POUI:FBS UP %BZ.POUI:FBS "CMBVG6ISName of Applicant: Date of Birth:
/BNFEFT"OUSBHTUFMMFST (FCVSUTEBUVN%BZ.POUI:FBS
Mailing Address: Marital Status:
"OTDISJGU 'BNJMJFOTUBOE
Phone Number: E-Mail:
5FMFGPOOVNNFS
International Driver´s Licence No.:
/VNNFSEFT*OUFSOBUJPOBMFO'àISFSTDIFJOT
Authorized Driver:
#FSFDIUJHUF'BISFS /P
/S /BNF/BDIOBNF 'JSTU/BNF7PSOBNF %BUFPG#JSUI(FC%BUVN *OUFSOBUJPOBM%SJWFSAT-JDFODF/P*OUFSOBUJPOBMFS'àISFSTDIFJO/S
Description of Vehicle to be insured:
#FTDISFJCVOHEFT[VWFSTJDIFSOEFO'BIS[FVHT :FBS
#BVKBIS .BLF)FSTUFMMFS 5ZQF5ZQ $IBTTJT/VNCFS'BISHFTUFMMOVNNFS "DUVBM$BTI7BMVF;FJUXFSU
Coverage Options: Liability $ 500.000
%FDLVOHTPQUJPOFO)BGUQøJDIU%4
Comprehensive & Collision
7PMMLBTLPJOLM5FJMLBTLP
Visited Countries: 64" ,BOBEB
4JHOFE"QQMJDBOU %BUF
6OUFSTDISJGU"OUSBHTUFMMFS Please sign by hand! Bitte per Hand unterschreiben! %BZ.POUI:FBS
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!
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#PEJMZ*OKVSZ$ 500.0001SPQFSUZ%BNBHF$ 200.000JODM .FEJDBM1BZNFOUXJUIBMJNJUPG$ 2.000
1FSTPOFOTDIÊEFO4BDITDIÊEFOFJOTDIM$ 2.000)FJMLPTUFO %FEVDUJCMF$PNQ$ 250$PMM$ 500
I fully understand and agree: 5IFJOTVSBODFQSPWJEFSEPFTOPUBTTVNFMJBCJMJUZVOUJM UIFBQQMJDBUJPOGPSNIBTCFFOTJHOFECZUIFBQQMJDBOU BOEVOUJMUIFJOTVSBODFQSPWJEFSIBTBQQSPWFEUIFBQ QMJDBUJPO
* VOEFSTUBOE UIBU OP MJBCJMJUZ XJMM CF BTTVNFE JG UIJT BQQMJDBUJPO DPOUBJOT BOZ GBMTF JOGPSNBUJPO PNJTTJPOT PSNJTSFQSFTFOUBUJPOTXJUISFHBSEUPUIFDPOUJOHFODZ SJTL
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öMNFOUPGUIFDPOUSBDU
Hiermit bestätige ich:
&T XJSE LFJOF %FDLVOH àCFSOPNNFO CFWPS EFS "O USBHTUFMMFS EFO "OUSBH VOUFSTDISJFCFO VOE EFS 7FSTJ DIFSFSEFN"OUSBH[VHFTUJNNUIBU
.JS JTU CFLBOOU EBTT LFJOF %FDLVOH HFXÊISU XJSE XFOOEJFTFS"OUSBHGBMTDIF"OHBCFO6OUFSMBTTVOHFO PEFS GBMTDIF %BSTUFMMVOHFO IJOTJDIUMJDI EFT [V WFSTJ DIFSOEFO3JTJLPTFOUIÊMU
.JSJTUCFLBOOUEBTTEJF1PMJDFTJDIBVUPNBUJTDIVN XFJUFSFT+BISWFSMÊOHFSU&JOF,àOEJHVOHJTUSFDIU[FJUJH CFJEFS'JSNB5PVS*OTVSF(NC)[VCFBOUSBHFO
%JF 4DIBEFOSFHVMJFSVOH FSGPMHU HSVOETÊU[MJDI àCFS EFO7FSTJDIFSFS
+FEFS 4DIBEFOGBMM JTU JOOFSIBMC WPO 4UVOEFO EFN 7FSTJDIFSFS[VNFMEFO%JF.FMEVOHLBOOUFMFGPOJTDI VOUFSEFSJOEFS1PMJDFBOHFHFCFOFO5FMFGPOOVNNFS FSGPMHFO8JSE EFS 4DIBEFO OJDIU GSJTUHFSFDIU HFNFM EFULBOOEFS7FSTJDIFSVOHTTDIVU[LPNQMFUUFOUGBMMFO *O BMMFO 'ÊMMFO HJMU EFS5FYU EFT BNFSJLBOJTDIFO7FSTJ DIFSFST
%JF 'JSNB5PVS*OTVSF (NC) JTU BVTTDIMJFMJDI BMT7FS NJUUMFSEFTBOHFCPUFOFO7FSTJDIFSVOHTTDIVU[FTUÊUJH &JOF)BGUVOHGàSEJF7FSUSBHTFSGàMMVOHEVSDIEFO7FSTJ DIFSFSXJSEOJDIUàCFSOPNNFO
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JA NEIN 8BSFO4JFPEFSFJOFSEFS[VTÊU[MJDIFO'BISFSJOEFOMFU[UFO+BISFO JONFISBMTFJOFO6OGBMMWFSXJDLFMU 8VSEF*IOFOPEFSFJOFNEFS[VT'BISFSJOEFOMFU[UFO+BISFO FJOF7FSTJDIFSVOHBCHFMFIOUPEFSHFLàOEJHU 4JOE4JFPEFSFJOFSEFS[VT'BISFSVOUFSVOEàCFS+BISFBMU 4JOE4JFàCFS+BISFBMUJTUFJOvNFEJDBMSFQPSUiFSGPSEFSMJDI )BUEBTCFUSFòFOEF'BIS[FVHHFTQSVOHFOFPEFSHFCSPDIFOF 4DIFJCFOPEFSTPOTUJHF4JDIFSIFJUTNÊOHFM )BCFO4JFPEFSFJOFSEFS[VT'BISFSLÚSQFSMJDIFPEFSHFJTUJHF .ÊOHFMPEFS#FFJOUSÊDIUJHVOHFO 8VSEF*IOFOPEFSFJOFNEFS[VT'BISFSEFS'àISFSTDIFJO FJOHF[PHFOWPSàCFSHFIFOEHFTQFSSUPEFSOJDIUHFXÊISU )BCFO4JFPEFSFJOFSEFS[VT'BISFSJO64",BOBEBFJOF"SCFJUTTUFMMF PEFSFJOFO8PIOTJU[ 4JOE4JFPEFSFJOFSEFS[VT'BISFS4UBBUTCàSHFS EFS64"PEFS,BOBEB *TU*ISTUÊOEJHFS8PIOTJU[PEFSEFSFJOFSEFS[VT'BISFSJOOFSIBMC WPO.FJMFOEFS64".FYJLP(SFO[F *TU*IS'BIS[FVH[VHFMBTTFOJO-PVJTJBOB.BTTBDIVTFUUT/FX+FSTFZ 4PVUI$BSPMJOBPEFS/PSUI$BSPMJOB *TUEFS'BIS[FVHXFSUIÚIFSBMT64 *TUEBT'BIS[FVHFJOHFTUVGUBMT4QPSUXBHFOPEFS )PDIMFJTUVOHTGBIS[FVH*TUEBT'BIS[FVH HFNJFUFUPEFS
HFMJFIFO8JFMBVUFUEBT,FOO[FJDIFOEFT'BIS[FVHFT 8FSJTU&JHFOUàNFSEFT'BIS[FVHFT 8FSJTU;BIMVOHTFNQGÊOHFSJN4DIBEFOGBMM /VSCFJ$BNQFSO8PIONPCJMFO .BF*ISFT'BIS[FVHFT )ÚIF#SFJUF-ÊOHF 'PSNVMBSBN 1$CFTDISFJCCBS
!
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8FMDIF#VOEFTUBBUFOEFS64"CFSFJTFO4JF *OXFMDIFN#VOEFTTUBBUEFS64"CFHJOOU*ISF3FJTF "OLVOGUTIBGFOJO64"GBMMT*IS'BIS[FVHOBDI64"WFSTDIJòUXVSEF 8FMDIFO#FSVGàCFO4JFEFS[FJUBVT JA NEIN 3FJTU*IS&IFQBSUOFSNJU 'BMMTKBCSBVDIFOXJSBVDIEBT(FCVSUTEBUVN 8FMDIFO#FSVGàCU*IS&IFQBSUOFSBVT 8BOOIBCFO4JF*ISFOFSTUFO'àISFSTDIFJOFSIBMUFO 8BOOIBU*IS&IFQBSUOFSEFOFSTUFO'àISFSTDIFJOFSIBMUFO /BNFEFT,';7FSTJDIFSFSTJO%FVUTDIMBOE 8JFMBOHFTJOE4JFEPSUTDIPOWFSTJDIFSUBitte immer beifügen:
,PQJFOt;VMBTTVOH 4FJUFCFJ,BVGJO64",BVGWFSUSBH t'àISFSTDIFJO OBUJPOBM t1BTT t7JTVNPEFS&45"#FTUÊUJHVOH t*OOFOTPXJF"VFOBVGOBINFO*ISFT8PIONPCJMT
Benötigen Sie die Police nicht für ein ganzes Jahr, senden Sie uns oder unserer Agentur bitte eine Kündigung per E-Mail, die folgenden Inhalt haben muss:
t1PMJDFOOVNNFS t,VOEFOOBNF t,àOEJHVOHTHSVOE t3àDLFSTUBUUVOHTBOTDISJGU Beispiel:
I……(Name)……… herewith cancel my policy ……(Nr)………. effective ……. (Datum)……. because I have to return to Europe. Please refund to my address: (Name und Heimat-Anschrift)
'PSNVMBSBN 1$CFTDISFJCCBS
!
Non – US Citizen Quote Request 10/12v
THE SUNRISE GROUP
QUOTE REQUEST FOR AUTO INSURANCE PROGRAM
Phone: (800) 478-7648 Fax: (386) 734-0903
FORM INFORMATION (Please Print or Type)
First Name: ____________________M. I.____ Last Name: __________________________________ Date of Birth: / /____
MM/ DD / YYYY
Home Country Address: _________________________________________________________________________________________ USA Address: _______________________________________________________________ Occupation: _______________________ Telephone: (Home) _____ ____________ Work: _____ _____________ E-Mail: ____________________________________________ USA entry visa type: __________________________________________
Driver’s License # :________________________ Date of original license ____/____/____ Expiration Date: _____/____/____ MM/ DD/ YYYY
MM/ DD/ YYYY State/country Licensed: __________ Prior insurance: __________________________ Pol#:________________ How many years with Prior Insurance Carrier: ________________________________________________________
Marital Status: ____________________________ Countries to be visited: ________________________________________________ Mail Policy to: [ ] APPLICANT [ ] ALTERNATE ADDRESS: ________________________________________________________
VEHICLE INFORMATION
Vehicle # I Type of Vehicle: [ ] Automobile [ ] Motorhome [ ] Motorcycle
Year: _________ Make: __________________ Model: _________________ Present Value: US $_______________ Vehicle Identification Number (VIN) __________________________________________________________________ Vehicle Usage: (Select one) ____ Pleasure ____Work <15 miles ____ Work >15 miles ____ Business
Length of Motorhome: ___________(Ft) License Plate No. and State Registered: ___________________________ CC of Motorcycle: __________________
Name & Address of Loss Payee: _____________________________________________________________________ Vehicle # 2 Type of Vehicle: [ ] Automobile [ ] Motorhome
Year: _________ Make: __________________ Model: _________________ Present Value: US $_______________ Vehicle Identification Number (VIN) __________________________________________________________________ Vehicle Usage: (Select one) ____ Pleasure ____Work <15 miles ____ Work >15 miles ____ Business
Length of Motorhome: ___________(Ft) License Plate No. and State Registered: ___________________________ Name & Address of Loss Payee: _____________________________________________________________________
COVERAGE INFORMATION Effective Date: ____________________
[ ] Package A: (Liability, Comprehensive, Collision) [ ] Package B: (Liability & Comprehensive only) [ ] Package C: (Liability Only) If your vehicle is over 20 years old, only Package C is available.
PAGE 2
The Following Information is required for all additional operators:
First Name: _______________M. I.: __ Last Name: __________________ Relationship to Insured: ____________ Date of Birth: ___/____/_____ Driver’s License #: ________________________ Occupation:__________________
Date of original license ___/___/____ Expiration date: ___/___/____ State Licensed: __________
MM/ DD / YYYY MM/ DD / YYYY
First Name: _______________M. I.: __ Last Name: __________________ Relationship to Insured: ____________ Date of Birth: ___/____/_____ Driver’s License #: ________________________ Occupation:__________________
Date of original license ___/___/____ Expiration date: ___/___/____ State Licensed: __________
MM/ DD / YYYY MM/ DD / YYYY
First Name: _______________M. I.: __ Last Name: __________________ Relationship to Insured: ____________ Date of Birth: ___/____/_____ Driver’s License #: ________________________ Occupation:__________________
Date of original license ___/___/____ Expiration date: ___/___/____ State Licensed: __________
MM/ DD / YYYY MM/ DD / YYYY
ADDITIONAL INFORMATION
YES NO
1. Have you or any driver listed above been involved in more than one motor vehicle accident or had a violation in the past 3 years?
2. Have you or any driver listed above had automobile insurance declined or cancelled in the past 3 years? 3. Are you or any driver listed above less than 25 years of age or over 75 years of age? ( a medical statement is
required if over 75)?
4. Does the described vehicle(s) have any cracked or broken glass or other safety deficiency? 5. Do you or any driver listed above have a physical or mental deficiency or impairment?
6. Have you or any driver listed above had a license revoked, suspended or refused?
7. Are you or any driver listed above employed in or have a permanent residence in the USA or Canada?
8. Are you or is any driver listed above a USA or Canadian citizen?
9. Is your permanent residence or the residence of any driver of this vehicle within 100 miles of the USA/Mexico border?
10. Is the vehicle(s) registered in Louisiana, Massachusetts, New Jersey, South Carolina or North Carolina? 11. Is the vehicle valued at more than $70,000 ?
12. Is the vehicle(s) considered a sports car or high-performance vehicle? 13. Is the vehicle(s) rented or borrowed?
I hereby warrant the truth of the above statements, and declare that I have not withheld any information whatsoever which might tend to influence the acceptance of this application. I understand that any false statement by me will constitute a breach of warranty and cause the policy to be void. I agree that this application shall be the basis of the Policy between the Company(s) and me. I understand that the policy expires after the period of coverage stated on this form ends and coverage is effective only after the application and full premium payment are received by the Company, or at a later date if specified.
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Für Zahlungen per Kreditkarte füllen Sie bitte das Formular aus und übersenden es per Post oder per Fax an:
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