PERSONAL AUTO APPLICATION

PROPOSED ON: 03/17/2003

PROPOSAL NUMBER: 129

MAILING ADDRESS:

SERVICE CENTER: 23      AGENT: 1749

MICKEY MOUSE
EP691 HWT P
STRATFORD WI 54484

JOHN FENGELS
150 E OAK STREET
ABBOTSFIELD WI 53039
OFFICE: (435) 343-2432

TERM LENGTH: 6 MONTHS

EFFECTIVE: 04/01/2003

NAMED INSURED:

MICKEY MOUSE
EP691 HWT P
STRATFORD WI 54484

DRIVER INFORMATION

DR NAME LICENSE NUMBER DATE OF BIRTH
1 MICKEY MOUSE K430-6647-1060-07 02/20/1971
2 MINNIE MOUSE K430-5017-1678-05 05/18/1971

YOUR COVERED AUTO(S) SUMMARY

AUTO YEAR MAKE MODEL/BODY VEHICLE ID TERR CLASS SYM/COST
1 1993 CHEVROLET PICKUP1500 1GC&C14C&P 16 888321 10
2 1991 FORD ESCORT LX 1FAPP11J&M 16 888320 10
3 2001 DODGE DURANGO 1B4&R28N&1 16 887120 14

YOUR COVERED AUTO(S)

1 - 1993 CHEVROLET PICKUP1500  "1GC&C14C&P" 

VEHICLE USE: TRAVEL TO WORK MORE THAN 15 MILES |  PRIMARY DRIVER: MICKEY MOUSE

DISCOUNTS APPLIED: MULTI-POLICY DISCOUNT | BUSINESS QUALITY | MULTI-VEHICLE

LIMITS OF LIABILITY
COVERAGES EACH PERSON EACH ACCIDENT TERM PREMIUM
BODILY INJURY LIABILITY $300 000 $300 000 $86
PROPERTY DAMAGE LIABILITY $100 000 $100 000 $45
MEDICAL PAYMENTS $1 000 $1 000 $8
TOTAL PREMIUM:  $139

2 - 1991 FORD ESCORT LX  "1FAPP11J&M" 

VEHICLE USE: TRAVEL TO WORK MORE THAN 15 MILES |  PRIMARY DRIVER: MINNIE MOUSE

DISCOUNTS APPLIED: MULTI-POLICY DISCOUNT | BUSINESS QUALITY | MULTI-VEHICLE

LIMITS OF LIABILITY
COVERAGES EACH PERSON EACH ACCIDENT TERM PREMIUM
BODILY INJURY LIABILITY $300 000 $300 000 $77
PROPERTY DAMAGE LIABILITY $100 000 $100 000 $40
MEDICAL PAYMENTS $1 000 $1 000 $7
TOTAL PREMIUM:  $124

3 - 2001 DODGE DURANGO  "1B4&R28N&1" 

VEHICLE USE: PLEASURE |  PRIMARY DRIVER: ALL OTHER

DISCOUNTS APPLIED: MULTI-POLICY DISCOUNT | BUSINESS QUALITY | MULTI-VEHICLE

LIMITS OF LIABILITY
COVERAGES EACH PERSON EACH ACCIDENT TERM PREMIUM
BODILY INJURY LIABILITY $300 000 $300 000 $60
PROPERTY DAMAGE LIABILITY $100 000 $100 000 $32
MEDICAL PAYMENTS $1 000 $1 000 $5
OTHER THAN COLLISION ACTUAL CASH VALUE LESS $50 DEDUCTIBLE $135
COLLISION ACTUAL CASH VALUE LESS $500 DEDUCTIBLE $90
AUDIO, VISUAL AND ELECTRONIC EQUIPMENT $1 000 $1 000 $34
TOTAL PREMIUM:  $356

UNINSURED & UNDERINSURED MOTORIST COVERAGE

THE LIMITS OF LIABILITY FOR THE FOLLOWING COVERAGES ARE PER POLICY LIMITS AND SHALL BE REDUCED AS A RESULT OF YOUR RECEIVING AMOUNTS FROM OTHER SOURCES BECAUSE OF YOUR "BODILY INJURY".

LIMITS OF LIABILITY
COVERAGES EACH PERSON EACH ACCIDENT TERM PREMIUM
UNINSURED MOTORISTS $300 000 $300 000 $16
UNDERINSURED MOTORISTS $300 000 $300 000 $22
TOTAL PREMIUM FOR THIS PROPOSAL $657


1 LOSS PAYABLE    VEHICLE  [3] 2001 DODGE DURANGO

  CHRYSLER FINANCE CORP
175 PATRICK BLVD
BROOKFIELD WI 53045

General Risk Selection

(1) Have you been rejected, cancelled or non-renewed?
Explain: 
No
(2) Have you had liens, judgements, foreclosures or bankruptcies in the past 3 years?
Explain: 
No
(3) List all prior losses or claims on this or other property:
(4) Are any vehicles not solely owned by and registered to the applicant?
Explain: 
No
(5) Do any vehicles have existing damage?
Explain: 
No
(6) Any other auto insurance in household? (include any provided by employer)
Explain: 
No
(7) Has the insured been insured with TRITECH in the last 6 months? No

SIGNATURES

The undersigned hereby agrees and represents that:

a) This application contains a full and true description and statement of the condition, situation, value, encumbrance, occupancy and title to the property to be insured with TRITECH Insurance Company to the best of my knowledge.
b) The answers to the questions and statements made are true.
c) Notification will be given to the agent of any changes(s).

NOTICE OF INSURANCE INFORMATION PRACTICES:

Personal information about you may be collected from persons other than you. Such information as well as consumer reports which may include credit information, collected by us or our agents, may in certain circumstances be disclosed to third parties. You have the right to review your personal information in our 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. Contact your agent for instruction on how to submit a request to us.

Any person who knowingly and with intent to defraud any insurance company or another 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 may subject the person to criminal and civil penalties, including recission of coverage.

APPLICANT’S STATEMENT:   I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true.

 X Applicant’s Signature ____________________     Date __________      Agent’s Signature __________________

 


PROXY

The agent should have applicant read and sign the following designation:

The undersigned hereby appoints the company, by any representative designated by its Board of Directors, attorney in fact for me to vote and act as my proxy at any meeting of policyholders of the TRITECH Insurance Company hereafter held, not attended by me in person, granting said attorney full authority to act for me in the transaction of any business coming before such meeting.

 X Applicant’s Signature ____________________       

 

TRITECH INSURANCE COMPANY