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PENNSYLVANIA AUTO APPLICATION

Application # PA0004608621 Date: 09/29/2008


Policy PA00572898A-00 Policy Effective 09/29/2008 at 12:21 P.M.

SHIRLEY L MURPHY Garaging Address:


2024 S REDFIELD ST 2024 S REDFIELD ST
PHILADELPHIA PA 19143 PHILADELPHIA PA 19143

DRIVER INFORMATION
DRIVER 1 DRIVER 2
Name SHIRLEY L MURPHY AHNYE MURPHY
DOB 09/21/1938 08/15/1984
Marital S S
SR-22 N N
Vio 04/20/2006 AT FAULT ACCIDE 09/08/2006 AT FAULT ACCIDE

VEHICLE INFORMATION
VEHICLE 1 VEHICLE 2
Yr Make 02 OLDSMOBILE 99 BUICK
Model INTRIGUE GL CENTURY CUSTOM
VIN 1G3WS52H92F189574 2G4WS52M8X1438311
Symbol 11 06
Owner SHIRLEY & AHNYE MURPHY SHIRLEY L MURPHY
Lien

COVERAGE AND 6 MONTH PREMIUM INFORMATION


COVERAGES LIMITS OF LIABILITY PREM VEH 1 PREM VEH 2
Bodily Injury Liability $15,000 Each Person/
$30,000 Each Accident $482 $405
Property Damage Liability $10,000 Each Accident INCL INCL
First Party Benefits
Medical Expense $5,000 Each Person $ 157 $141
Accidental Death $5,000 Each Person $9 $8
Uninsured Motorist Bodily Injury Stacked $15,000 Each Person/ $55 $55
$30,000 Each Accident
Underinsured Motorist Bodily Injury Stacked $15,000 Each Person/
$30,000 Each Accident $53 $53
VEH 1 VEH 2

Total Premium by Vehicle $756 $662

Total Premium All Vehicles $1,418

Application Fee $40


Downpayment with Application $287
Balance, including installment fees - 5 payments of $247
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION
OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE
SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND PAYMENT OF A FINE OF UP TO $15,000.

Form PA1000/0308 Please sign at the indicated area on the reverse side of this application and return application to the Company.
DISCOUNTS AND SURCHARGES
Applicable Discounts MULTI-CAR ANTI-LOCK BRAKE

Applicable Surcharges

APPLICANT QUESTIONNAIRE Explanation


Y/N
1. Have all residents of your household age 16 years or older been disclosed on this application? Y
2. Have all drivers, such as children away from home or in college or anyone who may operate your
vehicle on a REGULAR or OCCASIONAL basis been listed on this application? Y
3. Are all vehicles operated by residents of your household listed on this application? Y
4. Are any of the vehicles for which you are seeking coverage used in the course of business/employment to:
a. conduct consumer oriented sales, service or direct home sales; N
b. visit multiple locations without the transport of clients or patients; N
c. run occasional business related errands; N
d. transport materials, supplies, tools, etc. on a regular or occasional basis; or N
e. transport explosives, chemicals or flammable materials? N
5. Are any vehicles for which you are seeking coverage used for delivery purposes (for example: delivery of
pizza, newspapers, food or any other product)? N
6. Are any vehicles for which you are seeking coverage used during the course of an insured person’s
employment to transport people? (This does not include car-pooling to and from work but does include
transporting people for money.) N
7. Are any vehicles for which you are seeking coverage used for any other commercial or business purpose? N
8. Has any driver ever suffered from blackouts, seizures, epilepsy, diabetes or any other physical impairments? N
9. Does any driver take any regularly prescribed medicine? N
10. Has any driver been involved in an accident or reported a claim to an insurer in the past 5 years? N
11. Is there any existing damage or broken glass to the vehicles listed in this application? N
12. Does any driver drive out of state on a regular basis? N
APPLICANT APPROVAL
I hereby apply to the Company for a policy of insurance as set forth in this application on the basis of statements contained herein and do hereby agree to pay any
surcharges applicable under Company rules, which are necessitated by inaccurate statements. I understand that a routine inquiry may be made which will provide
applicable information concerning character, general reputation, personal characteristics, driving record, loss history, and mode of living; however, this report will
not include credit information. Upon request, the Company will confirm whether a consumer report was requested and utilized and if so, provide the name and
address of the consumer-reporting agency. I understand and agree that my payments may be due earlier if changes are made to this policy causing my premium
to increase. I understand that this policy shall be null and void or cancelled if such information is false or misleading or would materially affect
acceptance of the risk by the Company.
I hereby declare that all persons ages 16 or over who live with me and all other principal, regular, or occasional operators of my vehicles have been reported to the
Company and are listed on this application. I understand and agree that no coverage will be afforded under this policy if the insured vehicles are operated by any
resident of my household, unless that resident is listed as a named insured or is an additional driver on this application or the declarations page.
I hereby declare that my principal residence/place of vehicle garaging is in Pennsylvania, eleven (11) or more months a year and that I have disclosed any
frequent travel out of the Commonwealth of Pennsylvania. I hereby declare that I have reported herein any business use of the vehicles described in this
application.
I understand and agree that I must initiate my policy within 29 days of the date of this application; otherwise, the information contained in this application will
become invalid and I will need to complete another application to initiate a policy with the Company.
I understand that payment of premium is defined as being only when the premium payment tender clears, and no temporary or other coverage exists unless the
tender clears when initially submitted by the Company. I understand that partial payment is unacceptable and does not constitute coverage or continuation of
coverage under this policy.
I agree that the coverage afforded me under this policy is conditioned on the tender being honored by the financial institution when presented for payment. If the
down payment tender is not honored, the Company shall be deemed not to have accepted the tender, and the policy shall be voided from inception. I understand
that an NSF fee of $20.00 will be assessed to the balance due on my policy if any tender offered in payment is not honored. Imposition of such charge shall not
deem the Company to have accepted the tender unconditionally.
I understand and agree that my coverage with Safe Auto Insurance Company is not effective until:
1. Safe Auto Check by Phone: the date and time the checking account information is relayed to the Sales Representative;
2. Western Union or MoneyGram: the date and time printed on the receipt;
3. Credit Card: the date and time the transaction is approved by the creditor;
4. United States Postal Service Mailed Payments with a Legible Postmark: 12:01 A.M. the day after the postmark date shown on the envelope;
5. Payments Made by an Overnight Carrier with a Legible Received Date and Time: the day and time the overnight carrier receives the payment;
6. United States Postal Service Mailed Payments with an Illegible Postmark, United States Postal Service Mailed Payments with No Postmark, Payments Made
by an Overnight Carrier with an Illegible Received Date and Time, Payments Made by an Overnight Carrier with No Received Date and Time: 12:01 A.M. the
day the Company receives the payment;
7. Payments Delivered Via a Same Day Carrier: the date and time the Company receives the payment.
I certify that my vehicles do not have any existing physical damage except as indicated in Question 11 in the above questionnaire. I understand that my coverage
under this application will not apply to any currently existing physical damage whether listed above or not.
I understand that this policy of insurance contains important business use coverage restrictions and that coverage for business use is not provided unless I
elect to pay an additional fee to the Company for such use. I also understand that the Company may refuse to pay claims arising from the business use of a
covered vehicle unless I have paid the additional fee for such use.
I understand and agree that any fees charged to me are non-refundable and not part of the premium due; however, the application fee will be refunded
in the case of rescission. Fees may include a $40 application fee, a $10 billing fee (per installment), a $20 NSF fee, a $25 insured request cancellation fee, a
$10 reinstatement fee (per policy reinstatement), and a $10 SR-22 fee (per SR-22 filing and refiling).
In the event of a loss (including, but not limited to collision, theft, vandalism, hit and run), I agree to report it to the Company as soon as possible. I understand and
agree that failure to comply with this reporting requirement may result in the Company’s refusal to extend coverage for this loss.
I hereby certify that I have read and answered all questions in this application. I have read the insurance fraud statement and all the statements set forth in this
Applicant Approval section. I hereby certify that all information contained in this application is accurate and complete.

SIGNATURE OF
LICENSED AGENT DATE APPLICANT SIGNATURE

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