Sioux City General Construction
Resume:
IOWA
AUTO APPLICATION
Viking Insurance Company of
Wisconsin
Policy Number 114********
Effective Date: 11/20/2020
01:24 PM Central Time per Stevens Point, WI
My.DairylandInsurance.com
Named Insured(s)
JOHNSON, LARRY
1700 Jackson St Apt 305
Sioux City IA 51105
Phone: 712-***-****
Securus Insurance Group
Erin Loehr
5529 Military Rd
Sioux City IA 51109
Phone: 712-***-****
Premium and Coverage Information Type Auto Policy Term 6 Month Vehicle Level Coverages Limits Vehicle 1
Rated Driver 1
Bodily Injury Liability $100,000 Each Person/$300,000 Each accident $454.98 Property Damage Liability $100,000 Each accident $555.39 Medical Payments $2,000 Each Person $18.53
Comprehensive Not Selected
Collision Not Selected
Lienholder Deductible Not Selected
Rental Reimbursement N/A Not Selected
Roadside Assistance N/A Not Selected
Special Equipment N/A Not Selected
Subtotal Premium By Vehicle $1,028.90
Policy Level Coverages Limits Deductible Premium
Uninsured Motorist Bodily Injury $100,000 Each Person/$300,000 Each accident $28.59 Underinsured Motorist Bodily Injury $100,000 Each Person/$300,000 Each accident $28.70 Subtotal Premium By Policy $57.29
Premium Summary
Premium Subtotal $1,086.19
Policy Fee $10.00
Total Policy Premium $1,096.19
Total Amount Submitted $190.96
Pay Plan 5 Installments
Automatic Payments N
Fee Information
The following fees may be charged during the life of the policy. These fees may change. Reinstatement
Fee
Rewrite Fee SR22 Fee Late Fee Returned
Payment Fee
Billing Fee Automatic
Payments Billing
Fee
$15.00 $8.00 $0.00 $5.00 $25.00 $9.00 $4.00
Discount Information: None
Surcharge Information: None
IAA1101-0820 (Policy # 114********) Page 1 of 3
DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631 IAA1101-0820 (Policy # 114********) Page 2 of 3
Vehicle Information
Veh # Year Make Model VIN Vehicle Specifics Existing Damage
Veh
Use
Veh
Location
1 1996 Chevrolet PICKUP 1500 EXTENDED 1GCEK19R1TE167823 Truck, 8Cyls, 4wd, Pickup N P 51105 Driver Information
Drv # Name Date of Birth Gender License Number Financial Responsibility Marital
Status
License
State
1 JOHNSON, LARRY 07/13/1975 M S IA 585XX9186 SR22 IA Excluded Driver Information: None
Accident and Violation Information
Drv # Date of Occurrence Type Points Description of Occurrence 1 06/26/2018 Violation 5 Operating After Revocation 1 07/06/2018 Violation 4 Attempt to Elude Officer
Lienholder / Additional Insured /Additional Interest Information: None DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631 IAA1101-0820 (Policy # 114********) Page 3 of 3
Named Insured Confirmation
I understand and agree this application is a part of the policy. I understand and agree this policy does not take effect until the effective date and time listed on this application. I understand and agree if a payment made by me or on my behalf is not honored by the financial institution, it will not be considered a valid payment and coverage may not be afforded under this application and subsequent policy. I understand and agree any unpaid balance owed, including any fees, at the time of cancellation, non-renewal or expiration is a debt the Company may attempt to collect, and in addition to this unpaid balance, I must pay for any costs and attorney fees the Company may incur to collect this amount. I understand and agree the Company may obtain facts from third parties such as consumer reporting agencies or policy verification services that provide driving and claims histories on all drivers rated on this policy. I understand and agree new or updated consumer information may be used to calculate my renewal premium. I may access this information directly from the third party and correct it if it is inaccurate. I understand and agree this policy may be cancelled, rescinded, and/or coverage denied if this application contains any false statement, omission, or material misrepresentation that would have otherwise altered the Company’s evaluation of the policy.
I understand and agree I must report to the Company all persons of legal driving age or older who live with me temporarily or permanently, including all children at college. I understand I must report all persons who are regular operators of any vehicle to be insured, regardless of where they reside. I understand and agree none of the vehicles will be used to carry persons or property for compensation or a fee, or for retail or wholesale delivery, including, but not limited to, the pickup, transport or delivery of magazines, newspapers, mail or food.
I have had Special Equipment Coverage explained to me and fully understand it. I understand and agree when collision and/or comprehensive coverages are purchased, no coverage will exist for equipment that has not been installed by the original manufacturer of the vehicle unless Special Equipment Coverage has been purchased. I understand and agree the Company may use a credit based insurance score determined by information contained in my credit history. I understand and agree new or updated credit information may be used to calculate my renewal premium. I may access this information directly from the third party and correct it if it is inaccurate. I understand and agree it is my responsibility to report any change of vehicle location to the Company within 14 days of the change and I declare each vehicle listed in this application is garaged more than 50% of the time at the vehicle location listed.
Date Signed Time Signed
AM
PM
Named Insured's Signature
*
I hereby apply to the company for a policy of insurance. The above facts are true and complete. I understand this policy is to be issued in reliance upon these facts being true. NI1-D NI1-1ND
Date Signed Time Signed
AM
PM
Producer's Signature
*
I certify I have entered the information provided to me by the applicant(s) and I have read to them all of the confirmation statements on the application.
ESIGN_PRDUCR1-DT ESIGN_PRDUCR1
DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631 11/20/2020
Viking Insurance Company of Wisconsin
My.DairylandInsurance.com
Date Policy Number
Named Insured Agency
Agency Phone #
NOTICE OF UNDERWRITING DECISION
Agency Code:
JOHNSON, LARRY
1700 Jackson St Apt 305
Sioux City IA 51105
Securus Insurance Group
5529 Military Rd
Sioux City IA 51109
29032
11/20/2020 114********
Dear Customer:
Thank you for choosing us for your insurance needs. We look forward to serving you and appreciate your business. In addition to the information you provided when you applied for insurance, with your permission, we have ordered an insurance score from the following reporting organization: TransUnion National Disclosure Center
PO Box 1000
Chester, PA 19022
Your insurance score was one of the factors used to determine your insurance rate. This notice is to inform you that your credit information, as reported by the organization above, did not qualify you for our lowest available rate. The significant factor(s) affecting the score if any, are listed below. No mortg trades. Optimum value is mortg at least 12 mo old. Age 41-50 and avg mo trades on file is 60-89. Optimum is age <31 and avg mo trades on file 141+. 25-48 mo since last delinquency. Optimum is no delinq; max CC util last 12 mo >0% and <1%. There are 8+ third party collections. Optimum value is no collections. If you have reason to believe there may be an error on your report or that it is incomplete, you have the right to receive a free copy of it or dispute it by contacting the organization who provided the report, within 60 days. Please contact them at the address or phone number above, or request the report through the internet at: www.transunion.com. Reasonable exceptions are available to those who have had an Extraordinary Life Circumstance and because of which, credit information has been influenced. Examples of those circumstances include a catastrophic event, as declared by the federal or state government; serious illness or injury, or serious illness or injury to an immediate family member; death of a spouse, child, or parent; divorce or involuntary interruption of legally–owed alimony or support payments; identity theft; temporary loss of employment for a period of 3 months or more, if it results from involuntary termination; and military deployment overseas. To inquire further about these exceptions, please contact Customer Service via email at adycb5@r.postjobfree.com or via telephone at 1-800-***-****. It is important to note that while the above organization provided the report, they did not set the rate for your policy. Again, we appreciate your business and anticipate a continuing business relationship with you. GN1109-0915 (Pol #114********)
Page 1 of 1
DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631 SECURUS INSURANCE GROUP
VIKING INSURANCE COMPANY OF WISCONSIN
5529 MILITARY RD
SIOUX CITY IA 51109
November 20, 2020
Named Insured(s)
JOHNSON, LARRY
1700 JACKSON ST APT 305
SIOUX CITY IA 51105
Phone: 1-712-***-****
Agency Code: 29032
My.DairylandInsurance.com
Auto: 114********
PAYMENT RECEIPT
Please retain for your records.
Thank you for your payment to Dairyland Auto®.
Named Insured(s): JOHNSON, LARRY
Reference number: 95680671
Amount (US$): $190.96
Method of payment: Credit/Debit Card
Submitted: 11/20/2020 01:24 PM Central Time per Stevens Point, WI Thank you for your payment. Note: Any amount paid in excess of the remaining balance/term premium may result in a refund.
If you have questions, please contact Customer Service at adycb5@r.postjobfree.com or 1-800-***-****. GN1503-0915 Page 1 of 1
DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631 SECURUS INSURANCE GROUP
VIKING INSURANCE COMPANY OF WISCONSIN
5529 MILITARY RD
SIOUX CITY IA 51109
Named Insured(s)
JOHNSON, LARRY
1700 JACKSON ST APT 305
SIOUX CITY IA 51105
Phone: 1-712-***-****
Agency Code: 29032
My.DairylandInsurance.com
Print Date: 11/20/2020
Policy Number: 114********
PAYMENT SCHEDULE
The payment schedule for the term effective 11/20/2020 to 05/20/2021 will be: Due Date Amount (includes fees)
12/20/2020 $190.04
01/20/2021 $190.04
02/20/2021 $190.04
03/20/2021 $190.04
04/20/2021 $190.07
Sign up for automatic payments. Stop worrying about checks, postage or due dates! Have your payments withdrawn directly from your account.
Enroll in bill alerts. Receive text or email payment reminders when the due date's near, and never miss a payment again! You can even pay online directly from the text or email. Go paperless. View bills and policy documents anytime at My.DairylandInsurance.com. If you have questions, please contact Customer Service at adycb5@r.postjobfree.com or 1-800-***-****. We appreciate your business and look forward to serving you in the future. Nothing contained in this Schedule changes the effective dates listed on any outstanding bill, nonrenewal notice, expiration notice, or cancellation notice sent.
GN1515-0915 Process Date: 11/20/2020 - 01:24 PM Central Time per Stevens Point, WI Page 1 of 1 DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631 PREMIUM MUST BE PAID FOR COVERAGE TO BE IN FORCE
My.DairylandInsurance.com
Fold Here
IOWA AUTOMOBILE
INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy 114********
Effective Date 11/20/2020
Expiration Date 05/20/2021
Year 1996 Make Chevrolet
Model PICKUP 1500 EXTENDED
VIN 1GCEK19R1TE167823
Named Insured(s)
JOHNSON, LARRY
1700 Jackson St Apt 305
Sioux City IA 51105
Agency
Securus Insurance Group
5529 Military Rd
Sioux City IA 51109
Agency Phone 712-***-****
IN CASE OF AN ACCIDENT
Obtain the following information...
1. Name and address of each driver, passenger and
witness.
2. Name of insurance company and policy number for each vehicle involved.
COVERAGE COMPLIES WITH MINIMUM AMOUNT OF
LIABILITY INSURANCE REQUIRED. THIS CARD SERVES
AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY
FINANCIAL RESPONSIBILITY.
YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR
POSSESSION AND PRODUCE IT UPON DEMAND.
THIS CARD IS NOT PART OF YOUR POLICY AND IS
EFFECTIVE ONLY WHILE YOUR INSURANCE REMAINS IN
FORCE. THIS CARD NEITHER AFFIRMATIVELY NOR
NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
COVERAGE AFFORDED BY YOUR POLICY.
If you are in an accident, call us as soon as possible at 1-800-***-****. We are available 24 hours a day to take your call. See reverse side for additional information. GN3000-0915
DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631 Insured
NAME Last First Middle
ADDRESS
CASE NUMBER DRIVER'S LICENSE NUMBER BIRTH DATE SOCIAL SECURITY NO. CURRENT POLICY NUMBER EFFECTIVE FROM
The insurance hereby certified is provided by an:
MODEL YEAR TRADE NAME IDENTIFICATION NUMBER
SR-22 AAMVA UNIFORM FINANCIAL RESPONSIBILITY FORM
{ JOHNSON, LARRY
1700 Jackson St Apt 305 Sioux City IA 51105
585XX9186 07/13/1975
114********-**/20/2020
This certification is effective from 11/20/2020 and continues until cancelled or terminated in accordance with the financial responsibility laws and regulations of this State. OWNER'S POLICY: Applicable to (a) the following described vehicle(s), (b) any replacement(s) thereof by similar classification, and (c) any additionally acquired vehicles of similar classification for a period of at least 30 days from the date of acquisition.
X
1996 Chev 1GCEK19R1TE167823
State FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE Name of Insurance Company
Date By
SIGNATURE OF AUTHORIZED REPRESENTATIVE
THE FACE OF THIS DOCUMENT CONTAINS A WATERMARK LOGO. OPERATOR'S POLICY: Applicable to any non-owned vehicle. Iowa
The Company signatory hereto hereby certifies that it has issued to the above named insured a motor vehicle liability policy as required by the financial responsibility laws of this State, which policy is in effect on the effective date of this certificate. Viking Insurance Company of Wisconsin
11/20/2020
X
OSR-22-1007
Insured
NAME Last First Middle
ADDRESS
CASE NUMBER DRIVER'S LICENSE NUMBER BIRTH DATE SOCIAL SECURITY NO. CURRENT POLICY NUMBER EFFECTIVE FROM
The insurance hereby certified is provided by an:
MODEL YEAR TRADE NAME IDENTIFICATION NUMBER
SR-22 AAMVA UNIFORM FINANCIAL RESPONSIBILITY FORM
{ JOHNSON, LARRY
1700 Jackson St Apt 305 Sioux City IA 51105
585XX9186 07/13/1975
114********-**/20/2020
This certification is effective from 11/20/2020 and continues until cancelled or terminated in accordance with the financial responsibility laws and regulations of this State. OWNER'S POLICY: Applicable to (a) the following described vehicle(s), (b) any replacement(s) thereof by similar classification, and (c) any additionally acquired vehicles of similar classification for a period of at least 30 days from the date of acquisition.
X
1996 Chev 1GCEK19R1TE167823
State FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE Name of Insurance Company
Date By
SIGNATURE OF AUTHORIZED REPRESENTATIVE
THE FACE OF THIS DOCUMENT CONTAINS A WATERMARK LOGO. OPERATOR'S POLICY: Applicable to any non-owned vehicle. Iowa
The Company signatory hereto hereby certifies that it has issued to the above named insured a motor vehicle liability policy as required by the financial responsibility laws of this State, which policy is in effect on the effective date of this certificate. Viking Insurance Company of Wisconsin
11/20/2020
X
OSR-22-1007
DocuSign Envelope ID: EF1CFD24-B2D2-4672-960E-136830D53631
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