Telebind # 12345 Producer Code: Insurance Company: Anchor General Insurance Company (Gemini) PO BOX 509020 San Diego, CA 92150-9020 (800) 542-6246 Producer Name: Producer Phone: NO COVERAGE PRIOR TO THE DATE AND TIME OF THIS APPLICATION. Named Insured: Effective Date: Time: AM Term: PM Mailing Address (If PO BOX, Garaging Address Required): Garaging Address: City: State: Zip: City: State: Zip: DRIVERS AND HOUSEHOLD RESIDENTS: The applicant, spouse and all household residents 15 years of age or older, all regular operators of the vehicles described in this application, and all children who live away from home who drive vehicles, even occasionally, are listed below. DR No Complete Name M-F Married Y / N Relationship To Applicant Birth Date Date First Licensed Driver’s License ST Filing Y / N 1 2 3 4 5 EMPLOYMENT: DR No Occupation Description Name of Employer/School Complete Address 1 2 3 4 5 DRIVING HISTORY: Accidents and/or Convictions within the past 35 months. DR No First Name Incident Date Vehicle Code and/or Description DR No First Name Accident Date Were you at least 51% at fault? Was there Bodily Injury to any drivers/passengers? Estimated Cost of Property Damage Yes No Yes No $ $ $ DESCRIPTION OF THE VEHICLE(S): Veh Yr Make Model VIN Annual Miles Use B/P Discounts/Credits Multi Car GD Mature Driver 1 2 3 4
Transcript
Telebind # 12345
Producer Code:
Insurance Company:
Anchor General Insurance Company (Gemini)
PO BOX 509020 San Diego, CA 92150-9020
(800) 542-6246
Producer Name:
Producer Phone:
NO COVERAGE PRIOR TO THE DATE AND TIME OF THIS APPLICATION.
Named Insured:
Effective Date:
Time:
AM Term:
PM
Mailing Address (If PO BOX, Garaging Address Required):
Garaging Address:
City:
State:
Zip:
City:
State:
Zip:
DRIVERS AND HOUSEHOLD RESIDENTS: The applicant, spouse and all household residents 15 years of age or older, all regular operators of
the vehicles described in this application, and all children who live away from home who drive vehicles, even occasionally, are listed below. DR No
Complete Name M-F Married
Y / N
Relationship To Applicant
Birth Date Date First Licensed
Driver’s License ST Filing Y / N
1
2
3
4
5
EMPLOYMENT: DR No
Occupation Description Name of Employer/School Complete Address
1
2
3
4
5
DRIVING HISTORY: Accidents and/or Convictions within the past 35 months. DR No
First Name Incident Date Vehicle Code and/or Description
DR No
First Name Accident
Date
Were you at least 51% at fault?
Was there Bodily Injury to any drivers/passengers?
Estimated Cost of Property Damage
Yes No Yes No
$
$
$
DESCRIPTION OF THE VEHICLE(S):
Veh Yr Make Model VIN Annual Miles
Use B/P
Discounts/Credits Multi Car
GD Mature Driver
1
2
3
4
LOSS PAYEE / ADDITIONAL INSURED: Unless the full name and address is completed, the policy will not provide any rights or coverage
to any Lienholder and/or Additional Insured claiming to have any interest in the insurance herein applied for.
Veh LP / AI Name Address
COVERAGES AND LIMITS OF LIABILITY COVERAGE APPLIES ONLY WHERE PREMIUM IS INDICATED
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Liability Bodily Injury
$ ,000 Per Person $ $ $ $
$ ,000 Per Accident
Property Damage $ ,000 Each Accident $ $ $ $
Medical Payments $ Per Person $ $ $ $
Uninsured Motorist
Bodily Injury $ ,000 Per Person
$ $ $ $ $ ,000 Per Accident
Property Damage ACV or $3,500 Max Each Accident $ $ $ $
Comprehensive Ded Veh
1 Veh
2 Veh
3 Veh
4
$ $ $ $ Collision Ded
Collision Deductible Waiver $ $ $ $
Named Driver Buy Back Yes No
Total Per Veh $ $ $ $
SR FILING FEE $
POLICY FEE + ANTI THEFT FEE $
TRAVEL CLUB DUES $
TOTAL PREMIUM & FEES $
DO NOT BIND PHYSICAL DAMAGE COVERAGE WITHOUT INSPECTING THE VEHICLE. Yes No Explain any existing damage (photos must be submitted):
1. Are there any residents of your household, or anyone who regularly operates your vehicle, not disclosed on this application?
2. Are any vehicles used for delivery, such as pizza or newspaper delivery, or for any other commercial purpose?
3. Has any driver had his/her driver’s license suspended or revoked in the last three (3) years?
4. Does any driver have a physical or mental impairment that can affect their ability to operate a motor vehicle?
5. Has any driver had any moving convictions / accidents in the past 35 months that are not listed on his/her motor vehicle report?
6. Do you own any other motor vehicles not listed on this application?
7. Are any vehicles on this application not registered to the named insured?
8. Are any vehicles listed modified, customized, rebuilt, salvaged or damaged?
9. Has any driver filed any claims in the past 36 months?
10. Is any vehicle used in any way in the course of the insured’s or any driver’s occupation or business? Or, is any driver self-employed?
11. Are any vehicles listed on this application principally garaged in California less than 10 months per year?
Explanations for any Yes answers:
NOTE: POLICIES BILLED ON THE DIRECT BILL INSTALLMENT PLANS ARE SUBJECT TO A SERVICE FEE OF $13 PER INSTALLMENT. POLICIES THAT CANCEL ARE CHARGED A $15 REINSTATEMENT FEE. PAYMENT CONVENIENCE FEE OF $8 APPLIES TO ANY PAYMENT MADE BY POLICYHOLDER USING “PAY-BY-PHONE” OR EFT. (IF, EFT, INSTALLMENT FEE WILL BE WAIVED.)
*Note: Any payment returned unpaid is subject to a $27 return item fee.
COVERAGE RESTRICTIONS
1. DRIVER RESTRICTIONS: Coverage is issued on a restrictive policy and applies only to drivers listed on the application – ALL OTHER DRIVERS ARE EXCLUDED.
2.
COVERAGE RESTRICTION: Under the terms and conditions of this policy, the insurer may elect to repair the insured vehicle at a facility of its choice (Preferred Provider Organization). If there is no Preferred Provider Organization facility located within a twenty-five (25) mile radius of the address listed on your policy at the time of accident, we will not require repairs be effected by a Preferred Provider Organization. The term “Preferred Provider Organization” means repair or replacement facilities owned, operated, contracted by or otherwise affiliated with an organization which meets and maintains repair standards of excellence required by us and which ensures quality service and repair work on all business we direct to them. If you elect to use a facility other than a preferred provider, we will pay 75% of the loss, subject to policy provisions, notwithstanding any applicable deductibles.
3. SPECIAL EQUIPMENT: This policy is issued with $500 limit for original special equipment as available and installed by the manufacturer or its authorized dealer at the time the vehicle is purchased new. Additional special equipment is covered only if declared on the application or if endorsed to your policy.
DISCLOSURES
1. Failure to disclose all material facts, including traffic convictions and accidents, may result in policy cancellation. If cancelled, policy fees and earned premium are not refunded.
2.
If any premium remittance is not honored by the payor (for example an NSF check), coverage will be rescinded and the policy void from inception.
3.
Policy premium and/or policy period may be adjusted after review of motor vehicle records or other underwriting factors undisclosed or disclosed incorrectly on the application.
4.
I acknowledge that I received a copy of the “Auto Body Repair Consumer Bill of Rights” CBR1(2010).
5. I acknowledge that I received a copy of the “Privacy and Security Policy” GLBA (05/01).
MULTIPLE PROGRAM DISCLOSURE Anchor General Insurance Company currently has more than one Private Passenger Auto program within the State of California. These insurance programs were approved by the Department of Insurance based on a “Differences in Conditions”. Review the MULTIPLE PROGRAM DISCLOSURE attachment with your Broker in order to choose the program that best meets your personal needs.
I have selected Anchor General Insurance Company - Premier
I have selected Anchor General Insurance Company - Platinum
I have selected Anchor General Insurance Company – Motor Club Group
I have selected Anchor General Insurance Company - Gemini
A routine inquiry may be made regarding your character, general reputation, personal characteristics and mode of living. Upon your written request, we will disclose the nature and scope of the investigation. We will obtain your motor vehicle record for undisclosed convictions or accidents.
I UNDERSTAND THAT ANY EXISTING DAMAGE ON MY CAR AT THE TIME OF APPLICATION WILL NOT BE COVERED UNDER THIS INSURANCE.
I declare that the statements on this application are true and request the company to issue the insurance applied for in reliance on these statements. I understand that any material misrepresentation or omission will void coverage.
Applicant’s Signature: Date: Time: AM PM
Producer’s Signature: Date: Time: AM PM
ANNUAL MILEAGE STATEMENT I hereby attest that the mileage information provided is true and accurate. I understand that the premium is subject to adjustment based on actual miles driven annually. Understood, agreed and accepted by applicant.
Applicant’s Signature: Date:
AGREEMENT DELETING UNINSURED MOTORIST BODILY INJURY COVERAGE Uninsured Motorist Bodily Injury Coverage – The California Insurance Code requires an insurer to provide Uninsured Motorist coverage in each bodily injury liability policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Such section also permits the insurer and the applicant to delete such coverage completely or to delete such coverage when a motor vehicle is operated by a natural person or persons designated by name, or agree to provide such coverage in an amount less than that required by subdivision (m) of Section 11580.2 of the Insurance Code, but not less than the financial responsibility requirement. Uninsured Motorist coverage insures the insured, his heirs, or legal representatives for all sums within the limits established by law, which such person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death to him from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p) of Section 11580.2 of the Insurance Code. I HEREBY AGREE TO REJECT UNINSURED MOTORIST BODILY INJURY COVERAGE – This rejection shall be binding upon every insured to whom the policy applies while the policy is in force and shall continue to be so binding with respect to any continuation or renewal of the policy, or with respect to any other policy issued to the named insured by the same insurer or with respect to reinstatement of the policy within 30 days of any lapse thereof. I HAVE READ AND UNDERSTAND THE FOREGOING WAIVER AND AFFIX MY SIGNATURE HERETO WITH FULL KNOWLEDGE THAT I AM WAIVING PROTECTION UNDER UNINSURED MOTORIST COVERAGE. Applicant’s Signature: Date:
AGREEMENT DELETING UNINSURED MOTORIST PROPERTY DAMAGE / COLLISION DEDUCTIBLE WAIVER DELETION OF UNINSURED MOTORIST PROPERTY DAMAGE COVERAGE – The California Insurance Code requires insurers to offer coverage for damage to the insured motor vehicle to the extent that you are legally entitled to recover from the owner or operator of the uninsured motor vehicle, caused by an uninsured motor vehicle, that either 1) pays for the collision deductible on the insured motor vehicle when you have purchased collision coverage: or 2) pays for the damage to the insured motor vehicle and shall not exceed the smaller of the actual cash value of the insured motor vehicle or $3500, whichever is less. I HEREBY AGREE TO REJECT UNINSURED MOTORIST PROPERTY DAMAGE COVERAGE – This rejection shall be binding upon every insured to whom the policy applies while the policy is in force and shall continue to be so binding with respect to any continuation or renewal of the policy, or regarding any other policy which extends, changes, supersedes or replaces the policy issued to the named insured by the same insurer or regarding reinstatement of the policy within 30 days of any lapse thereof. I HAVE READ AND UNDERSTAND THE FOREGOING WAIVER AND AFFIX MY SIGNATURE HERETO WITH FULL KNOWLEDGE THAT I AM WAIVING PROTECTION UNDER UNINSURED MOTORIST PROPERTY DAMAGE COVERAGE. Applicant’s Signature: Date:
The insurance company and the travel club providers are separate business entities offering separate coverage and benefits. The Anchor General Insurance Company (“Company”) policy for which you are applying is a Group Insurance Plan, which only offers private passenger automobile insurance to members of a predefined group. As a result, the named insured must be a member of this group – Nation Safe Drivers Travel Club (“Travel Club”). If the private passenger automobile insurance application is accepted and a private passenger automobile insurance policy is issued by the Company, the named insured shown on the Anchor General Insurance Company application for insurance will simultaneously be enrolled as a member of the Travel Club. Once a private passenger automobile insurance policy is issued by the Company and a Travel Club membership is established, any cancellation or expiration of your private passenger automobile insurance policy issued by the Company will result in the cancellation of your Travel Club membership effective the same date. Your down-payment is a combination of the premiums and fees for your private passenger automobile insurance policy application and the membership dues for your Travel Club membership. Please sign me up for membership in the Nation Safe Drivers Travel Club. Applicant’s Signature: Date:
ANCHOR GENERAL INSURANCE COMPANY P.O. BOX 509020
San Diego, CA 92150-9020
AGIC_CA_NDE_1209
NAMED DRIVER EXCLUSION ENDORSEMENT
THIS ENDORSEMENT FORMS A PART OF POLICY # : ISSUED TO : ENDORSEMENT EFFECTIVE DATE : ENDORSEMENT EXPIRATION DATE : INDEFINITELY UNTIL DELETED BY NAMED INSURED INSURANCE COMPANY : ANCHOR GENERAL INSURANCE COMPANY PROGRAM ADMINISTRATOR : ANCHOR GENERAL INSURANCE AGENCY, INC. It is understood and agreed that coverage and our obligation to defend under this policy shall not apply nor accrue to the benefit of any insured or any third party claimant while any motor vehicle is being used or operated by any of the persons designated below. You agree to reimburse us for any payment made by us to a loss payee because of loss arising from the use or operation of your insured car by a person listed below. This endorsement shall apply to any use or operation of a motor vehicle, regardless of whether such use is permissive or not, including without limitation the negligent or alleged negligent entrustment of a motor vehicle to any designated person. NAME OF INDIVIDUAL RELATION TO INSURED DATE OF BIRTH OR LICENSE # 1. 2. 3. 4. 5. 6. The California Insurance Code requires an insurer to provide uninsured motorist coverage in each bodily injury liability policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also permit the insurer and the applicant to delete such coverage completely or to delete such coverage when a motor vehicle is operated by a natural person or persons designated by name. Uninsured Motorist coverage insurers the insured, his or her heirs, or legal representatives for all sums within the limits established by law, which the person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death to the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or resident of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p) of Section 11580.0 of the California Insurance Code. DELETION AGREEMENT Pursuant to the authority of the California Insurance Code, the undersigned, a named insured in the policy listed above, and the company providing the insurance agree to the deletion of all coverage and obligation to defend, and including, specifically uninsured motorist coverage as described above. The undersigned further agrees to reimburse the company providing the insurance for any payment made to a loss payee because of a loss arising from the use of operation of any vehicle by any person designated by name above. The deletion shall be binding upon every insured to whom such policy or endorsement provisions apply while such policy is in force, and shall continue to be so binding with respect to any continuation, renewal, or replacement of such policy by the named insured, or with respect to reinstatement of such policy within 30 days of any lapse thereof. DO NOT SIGN THIS AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND IT. SIGNATURE OF APPLICANT: DATE:
AGIC_CA_BE_1209
ANCHOR GENERAL INSURANCE COMPANY P.O. BOX 509020
San Diego, CA 92150-9020
BUSINESS PURSUITS EXCLUSION ENDORSEMENT
It is understood and agreed that all coverage and any obligation to defend is deleted from the personal automobile policy to which this endorsement is attached while any motor vehicle covered under this policy is used in any way in the Named Insured’s or any driver’s business pursuits, occupation, trade, or profession; is used for hire, or for delivery of products or services; or is used in any employment in an emergency occupation, including, but not limited to, police, fire, and paramedic, on a full-time, part-time, or volunteer basis. If the Insurance Company listed above is required to make any payments under this policy because of a loss involving a motor vehicle to which this exclusion applies, the Named Insured must repay us those payments and any expenses. This exclusion shall be binding upon every insured to whom such policy or endorsement provisions apply while such policy is in force, and shall continue to be so binding with respect to any continuation, renewal, or replacement of such policy by the named insured, or with respect to reinstatement of such policy within 30 days of any lapse thereof.
Insured’s/Applicant’s Signature Date
Anchor General Insurance Company Privacy and Security Policy
Safeguarding you and your family's personal information is something we take very seriously at Anchor GeneralInsurance Company.
At Anchor General Insurance Company, our policy is to maintain appropriate confidentiality with regard to allpersonal information obtained in the course of doing business with you. The Privacy Policy stated below includesexamples of the types of nonpublic personal information we collect. These examples are illustrative and are notconsidered a complete inventory of our information collection.
Below is Anchor General Insurance Company's privacy pledge to our customers:
Information We May CollectAnchor General Insurance Company only collects personal information about you when it is necessary toconduct the business of insurance. We limit the collection of personal information to what we reasonably believeis needed to service your account. Anchor General Insurance Company may collect nonpublic personalinformation about you from the following source:
• Personal information you share with us directly or through your broker, such as the information on your insuranceapplication, a policy change request, or any other forms you may complete.
• Personal information you provide or which is being obtained through the process of handling a claim, includingmedical information, such as from an accident report.
• Personal information about you from your transactions with us, our affiliates, or others, such as the number ofyears you have been a policyholder with an insurance company or the types of coverage you purchase.
• Personal information about you from a consumer reporting agency, such as a Credit Report or a Motor VehicleReport.
You have the right to obtain access to certain items of information we have collected about you, and you havethe further right to request correction of information if you feel it is inaccurate. You may contact Anchor GeneralInsurance Agency, Inc. for further information concerning these rights.
Information We May Disclose and to Whom We May Disclose InformationInformation gathered on behalf of Anchor General Insurance Company is not disclosed to anyone other than toparties aiding us in delivering products and services to you, and as required or permitted by law. When possible,we advise our vendors and other non-affiliated third parties, to whom we legally provide your personalinformation in the course of conducting our insurance business, of our Privacy Policy. We make every effort touse vendors whose approach to customer privacy reflects our own.
Our Security ProceduresAnchor General Insurance Company restricts access to nonpublic personal information about you to thoseemployees whom we determine have a legitimate business purpose to access such information in connectionwith the provision of products or service to you. We employ security techniques designed to protect our customerdata.
Changes to the Privacy PolicyWe reserve the right to modify or supplement this Privacy Policy at any time. If at some point in the future werevise our privacy practices that effect your personal information, we will notify you prior to introducing anychanges.
If you have any additional questions regarding this Privacy and Security Policy, please contact the CustomerService Department at:
Anchor General Insurance Agency, Inc.P.O. Box 509020
San Diego, CA 92150-90201-800-54-ANCHOR
GLBA (5/01)
AUTO BODY REPAIR CONSUMER BILL OF RIGHTSAmended effective January 1, 2010
A consumer is entitled to:
1. Select the auto body repair shop to repair auto body damage covered by the insurance company.An insurance company shall not require the repairs to be done at a specific auto body repairshop.
2. An itemized written estimate for auto body repairs and upon completion of repairs, a detailedinvoice. The estimate and the invoice must include an itemized list of parts and labor along withthe total price for the work performed. The estimate and invoice must also identify all parts asnew, used, aftermarket, reconditioned, or rebuilt.
3. Be informed about coverage for towing and storage services.
4. Be informed about the extent of coverage, if any, for a replacement rental vehicle while adamaged vehicle is being repaired.
5. Be informed of where to report suspected fraud or other complaints and concerns about autobody repairs.
6. Seek and obtain an independent repair estimate directly from a registered auto body repair shopfor repair of a damaged vehicle, even when pursuing an insurance claim for repairing the vehicle.
Complaints within the jurisdiction of the Bureau of Automotive RepairComplaints concerning the repair of a vehicle by an auto body repair shop should be directed to:
Toll Free (866) 799-3811
California Department of Consumer Affairs/Bureau of Automotive Repair
10240 Systems Parkway
Sacramento, CA 95827
The Bureau of Automotive Repair can also accept complaints on its website at: www.autorepair.ca.gov
Complaints within the jurisdiction of the California Insurance CommissionerAny concerns regarding how an auto insurance claim is being handled should be submitted to the
California Department of Insurance at:(800) 927-HELP or (213) 897-8921
California Department of Insurance
Consumer Services Division
300 S. Spring Street
Los Angeles, CA 90013
The California Department of Insurance can also accept complaints on its website at:
www.insurance.ca.gov
CBR1(2010)
Multiple Program Disclosure
Anchor General Insurance Company currently has more than one Private Passenger Auto program within the State of California. Theseinsurance programs were approved by the Department of Insurance based on a "Differences in Conditions". Following is a summary of someof the "Differences in Conditions". (Please consult the policy for the exact language and any restrictions and/or exclusions). Review thisinformation with your Broker in order to choose the program that best meets your personal needs.
PROGRAM ANCHOR PLATINUM ANCHOR MOTOR CLUB
Membership None required Must be member of an approved motor club group
Liability Coverage (ifincluded)
• 1 1/2 ton Pickup is acceptable• Covered automobile does not include vehicles with less
than four or more than six wheels• Utility Automobile is defined by rated load capacity not
exceeding 3000 pounds• $250 limit for cost of bail bonds• $75 per day limit for loss of earnings due to attendance
at hearings or trials, 10 day maximum• Available Liability limits: 15/30/5, 15/30/10, 25/50/10,
50/100/25, and 100/300/50
• 1 ton Pickup is acceptable• Covered automobile does not include vehicles with less
than or more than four wheels• Utility Automobile is defined by rated load capacity not
exceeding 2000 pounds• $100 limit for cost of bail bonds• No coverage for loss of earnings due to attendance at
hearings or trials• Available Liability limits: 15/30/5 or 15/30/10
Medical Payments (ifincluded)
Available Available
Physical DamageInsurance for your Car(if included)
• $100 limit for storage charges• Rental Reimbursement provided for theft of entire
vehicle at $20 per day/30 days maximum• Maximum limit of $40,000 for any one vehicle• $200 limit for personal effects if theft of entire vehicle• Covered losses that are repaired outside the network of
contracted repair facilities are subject to a 30% penalty• $500 limit for special equipment• $500 Loss Payee deductible
• $75 limit for storage charges• Rental Reimbursement provided for theft of entire
vehicle at $15 per day/30 days maximum• Maximum limit of $50,000 for any one vehicle• No coverage for personal effects• Covered losses that are repaired outside the network of
contracted repair facilities are subject to a 20% penalty• $1000 limit for special equipment• $500 Loss Payee deductible
PROGRAM ANCHOR PREMIER ANCHOR GEMINI
Membership None required Must be member of an approved travel club group
Liability Coverage (ifincluded)
• 1 ton Pickup is acceptable• Covered automobile does not include vehicles with less
than or more than four wheels• Utility Automobile is defined by rated load capacity not
exceeding 2000 pounds• $100 limit for cost of bail bonds• No coverage for loss of earnings due to attendance at
hearings or trials• Available Liability limits: 15/30/5, 15/30/10
• 1 ton Pickup is acceptable• Covered automobile does not include vehicles with less
than or more than four wheels• Utility Automobile is defined by rated load capacity not
exceeding 2000 pounds• $150 limit for cost of bail bonds• No coverage for loss of earnings due to attendance at
hearings or trials• Available Liability limits: 15/30/5 or 15/30/10
Medical Payments (ifincluded)
Not available Available
Physical DamageInsurance for your Car(if included)
• $75 limit for storage charges• Rental Reimbursement provided for theft of entire
vehicle at $15 per day/30 days maximum• Maximum limit of $50,000 for any one vehicle• No coverage for personal effects• Covered losses that are repaired outside the network of
contracted repair facilities are subject to a 20% penalty• $1000 limit for special equipment• $250 Loss Payee deductible
• $150 limit for storage charges• Rental Reimbursement provided for theft of entire
vehicle at $20 per day/30 days maximum• Maximum limit of $50,000 for any one vehicle• $100 limit for personal effects if theft of entire vehicle• Covered losses that are repaired outside the network of
contracted repair facilities are subject to a 25% penalty• $500 limit for special equipment• $500 Loss Payee deductible
Beneficiary: PLEASE ENROLL ME IN THE TRAVEL PROGRAM. This is atravel club membership and not insurance. I further understand that this Membership is optional and is not required in order to purchase or obtain insurance and that MY acceptance of the Membership is voluntary.
SIGNATURE OF APPLICANT
PLAN OPTIONS
BENEFIT PLAN 201/205 PLAN 202/206 PLAN 203/207 PLAN 204/208
Accidental Death &Dismemberment
$10,000 $7,500 $5,000 $2,500
Excess Accidental MedicalExpense
$1,000 $750 $500 $250
Daily In-HospitalConfinement
$125 per day $75 per day $50 per day $25 per day
Travel Discounts 5% 4% 3% 2%
Credit Card Protection Included Included Included Included
Rental-A-Car Discounts Included Included Included Included
Lost Luggage Protection Included Included Included Included
Emergency Cash $100 $50 $25 $10
ALL LIMITS STATED ABOVE ARE AGGREGATE POLICY LIMITSCoverage defined applies only to the person whose name is typed on this enrollment form. In the event the Family
Plan (205,206,207 or 208) is selected, the Family Members are defined as the Applicant's legal spouse and the Applicant's legaldependents who legally reside in the Applicant's household. All limits are aggregate limits.
PLEASE READ YOUR SYNOPSIS OF BENEFITS CAREFULLY FOR FULL EXPLANATION OF BENEFITSNSD -TRAVEL APP 042104 182
