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APPLICANT QUESTIONNAIRE -- TO BE COMPLETED BY THE APPLICANT IN HIS/HER OWN HANDWRITINGPLEASE MAKE SURE THE APPLICANT INITIALS EACH RESPONSE
1 Have all drivers, such as children away from home or in college,who may operate your vehicle(s) on a REGULAR basis or anyINFREQUENT bases been listed on this application? If no, pleaseexplain.
Yes No _______ Initial
2 Have all residents of your household been disclosed on thisapplication? If no, please explain.
Yes No _______ Initial
3 Do any operators have a medical, nervous, mental, or physicalcondition which could impair their ability to safely operate avehicle? If yes, please explain.
Yes No _______ Initial
4 Is every operator a United States citizen? Yes No _______ Initial
5 Do you understand that we do not cover losses if your vehicle isbeing operated by an undisclosed driver(s) resident in yourhousehold? If no, please explain.
Yes No _______ Initial
6 Are all vehicles in the household listed on this application? If no,please explain.
Yes No _______ Initial
7 Are any vehicles used for business purposes? (Examples: salescalls, driving to job sites, etc.) If yes, please explain.
Yes No _______ Initial
8 Are any vehicles used for delivery purposes or for any othercommercial purpose? (Examples: pizza or newspaper delivery.) Ifyes, please explain.
Yes No _______ Initial
9 Do you understand that we do not cover losses if your vehicle isbeing used for commercial purposes?
Yes No _______ Initial
10 Is there any unrepaired damage or glass breakage to anyvehicle(s)? If yes, please explain.
Yes No _______ Initial
11 Are any operators a member of the armed forces? If "yes", wherestationed?
Yes No _______ Initial
12 I agree to notify Infinity of any member of my household age 14 andolder, licensed or not, and any change in driving status for anyperson currently listed or added on my policy, in the future. (Byanswering "Yes" I certify that I have read and understand myobligation pursuant to this provision and that this obligationcontinues for this policy, or any continuation, renewal orreplacement of this policy by you.)
Yes No _______ Initial
13 Annual mileage driven for:VEHICLE 1 VEHICLE 2 VEHICLE 3
14 Yes No Yes No Yes No
15 Type
Residence:
Apartment Condo Townhouse House Mobile Home Do you: Own Rent Other
Explanations:
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Form Number Page 1 of 1
Underwritten by:
UNINSURED/UNDERINSURED MOTORIST COVERAGE
SELECTION/REJECTION FORM GEORGIA
Named Policy Insured: ID Number: In accordance with the provision of state law respecting Automobile Liability Insurance which permits the named insured in the policy to reject or accept Uninsured Motorist Coverage, the undersigned insured does understand that he or she has the right to purchase Uninsured Motorist Coverage with limits not to exceed the liability limits of this policy. The undersigned insured does hereby, for this policy and any renewal thereof, reject or accept as indicated below, such coverage provided for protection of persons insured under this policy who would legally be entitled to recover damages from the owner or operator of an uninsured motor vehicle because of bodily injury, sickness or disease, including death resulting therefrom, and for injury to or destruction of property.
REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE
I Reject Uninsured/Underinsured Motorists Coverage and understand that my policy will not provide Uninsured/Underinsured Motorists Bodily Injury and Uninsured/Underinsured Motorists Property Damage Coverage.
I understand Uninsured/Underinsured Motorists coverage and have been advised of the premiums. I understand and agree that my selection applies not only to this policy, but also to all renewals or replacements thereof, unless I instruct the Company to the contrary in writing. I understand that by rejecting Uninsured/Underinsured Motorists Bodily Injury and Uninsured/Underinsured Motorists Property Damage Coverage my policy will not provide this coverage. Insured Signature ____________________________________Date______________________ Time _________________ AM PM
SELECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE/OPTIONS Uninsured Motorist Bodily Injury: Uninsured Motorist Property Damage: $25,000 / $50,000 $250 Deductible $25,000 each accident $50,000 / $100,000 $250 Deductible $50,000 each accident $100,000 / $300,000 $250 Deductible $100,000 each accident $500 Deductible $25,000 each accident $500 Deductible $50,000 each accident $500 Deductible $100,000 each accident $1,000 Deductible $25,000 each accident $1,000 Deductible $50,000 each accident $1,000 Deductible $100,000 each accident I Accept Uninsured Motorist Coverage Added on to At-Fault Liability Limits Option at the limits selected above I Reject Uninsured Motorist Coverage Added on to At-Fault Liability Limits Option and Accept Uninsured Motorist Coverage Reduced
by At-Fault Liability Limits Option at the limits selected above All coverage and options for Uninsured Motorist Coverage have been offered and fully explained to me, and I knowingly made the selection above as reflected by the “X” in the appropriate box. I understand Uninsured Motorist Coverage Added on to At-Fault Liability Limits and Uninsured Motorist Coverage Reduced by At-Fault Liability Limits and have been advised of their premiums. I understand that by rejecting Uninsured Motorist Coverage Added on to At-Fault Liability Limits my policy will not provide this coverage and I accept the Uninsured Motorist Coverage Reduced by At-Fault Liability Limits Option. I understand and agree that my selection applies not only to this policy, but also to all renewals or replacements thereof, unless I instruct the Company to the contrary in writing Insured Signature _______________________________________ Date ___________________ Time ________________ AM PM
Uninsured Motorist Informational Notice
If you have chosen to accept Uninsured Motorists coverage from your automobile insurance company, and have any questions after reading this statement regarding Uninsured Motorists coverage or the amount of coverage you have selected, your agent or company representative will be able to assist you. You should have chosen the amount of Uninsured Motorists coverage you want based on this question: If I get hit by someone with little or no liablity insurance, how much protection do I need to cover the cost associated with car repair, medical bills, other expenses, and lost wages? If the person who hits your automobile has no liability coverage or liability coverage equal to or less than the Uninsured Motorists amount you chose, your total automobile insurance recovery (from all companies involved) may not exceed the amount of Uninsured Motorists coverage you chose. The purpose of this notice is informational. This notice does not change or replace the wording in your policy. X_________________________________ _____________ Signature of Applicant Date
INFINITY VALUE ADDED PROGRAM
LESSOR LIABILITY ENDORSEMENT ACKNOWLEDGMENTFORM #03940 N1102
I understand that I have requested the 'Lessor Liability Endorsement' to be included as part of my contract of insurance. I have signed this form as
an indication that I have read, understood and agree with the endorsement and the limitations it places on my coverage as outlined therein and
below.
I understand that the endorsement is only effective on a vehicle that has been leased by me for a period of at least six (6) months as documented by
a standard form lease agreement with expressly stated insurance coverage requirements.
I understand that the limits of coverage for damages I become legally obligated to pay, as defined by my policy, shall be those limits listed on my
Declarations Page.
I understand that this endorsement and the coverage provided therein will only apply to damages that my lessor becomes legally obligated to pay
and that arise from and are related to a loss covered under my policy.
I understand that the coverage provided by this endorsement is in addition to that listed on my Declarations Page and is only available to indemnify
my lessor pursuant to the terms listed in the endorsement.
I understand that the coverage provided by this endorsement shall in no event increase the limits of liability for any damages I become legally
obligated to pay pursuant to the terms of my policy.
I also understand that the lessor is not responsible for payment of my premium.
Applicant's Signature Date
Applicant's Signature Date
AGREEMENT VOIDING AUTOMOBILE INSURANCE WHILE A CERTAIN PERSON IS OPERATING YOUR INSUREDAUTO
FORM #03937 N1102
In consideration of YOUR premium payment, it is agreed that, with respect to the insurance afforded under this policy, or any continuation, renewal or
replacement of the policy BY you, or the reinstatement of this policy within 30 days of any lapse thereof, WE shall not be liable for loss, damage, or
liability caused when YOUR INSURED CAR is being driven or operated by the person named below.
SOCIAL SECURITY NUMBER OF PERSON BEING EXCLUDED
It is further agreed that in the event WE shall, because of any interest, become obligated to pay any sum or sums of money because of loss for which
there would be no coverage because of this agreement, YOU will reimburse US for any and all sums, costs and expenses paid or incurred by US.
CAUTION: DO NOT SIGN THIS AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND IT.
NAME OF PERSON BEING EXCLUDED
APPLICANT'S SIGNATURE DATE TIME
INFINITY VALUE ADDED PROGRAM
AUTHORIZATION FOR INSURED'S ELECTRONIC FUND TRANSFERS
Fax voided personal check along with this form to be set up for IEFT and retain the original for your records:1-888-682-8231 - Attn: GENERAL ACCOUNTING
INSURED'S NAME:
POLICY NUMBER: EFF DATE:
I, give Infinity the authorization to withdraw the appropriate Infinity money that has beendeposited into my account
I further authorize the financial institution named below to accept such automatic deposits to or withdrawals from myaccount by Infinity and to automatically credit or debit, as the case may be, such amounts.
Name of Bank:
Address:
City, State, Zip:
Phone:
The routing and account numbers provided on the copy of the voided personal check will be used to set up theInsured's Electronic Funds Transfer (i.e. IEFT).
I understand that I may cancel this authorization at any time. To cancel, I must give notice to the company, in writing. Mycancellation will become effective when the company receives written notice of cancellation and has a reasonable periodof time upon which to process the change.
I further understand that all automatic deposits to or withdrawals from my account under this authorization willbe subject to all rules, regulation, agreements, and disclosure statements of the company and the institutiongoverning accounts and pre-authorized transfers to and from this account.
Your bank will be notified that Infinity will have authorization to make withdrawals or transfers on this account.
Name (Print)
Address (Print)
Agent's Name
Insured's Signature Date
ANY CHANGES TO EXISTING INSURED'S EFTCHECKING ACCOUNT OR BANK, MUST BE SUBMITTEDIN WRITING IMMEDIATELY TO:
Program: VALUEADDED
GENERAL ACCOUNTINGINFINITY INSURANCE COMPANY2204 LAKESHORE DRIVEPO BOX 830189BIRMINGHAM, AL 35283
03895 N0902