Form_SCTNID_CTGRY.WA********_APPLICAT

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Policy Number: 917411103

Policyholder:

Gerald Fry

October 10, 2017

Application for Insurance

Please review and sign where

indicated

Policy and premium information for policy number 917411103

Insurance company: Progressive Direct Insurance Co PO Box 31260

Tampa, FL 33631

Named insured: Gerald Fry

921 S Pines Rd

46

Spokane, WA 99206

Home: 1-509-***-****

Financial responsibility vendor: EXPERIAN

1-888-***-****

Policy period: Oct 11, 2017 - Apr 11, 2018

Effective date and time: Oct 11, 2017 at 12:01 A.M. Total policy premium: $333.00

Initial payment required: $55.52

Initial payment received: $55.52

Payment plan: 6 payments

Drivers and resident relatives

You, your spouse, and all resident relatives 15 years of age or older, all regular drivers of the vehicles described in this application, and all children who live away from home who drive these vehicles, even occasionally, are listed below. Your total policy premium can be affected by all persons of driving age. While designating drivers as List Only or Excluded may increase policy premium, the violation and accident history of Excluded and List Only drivers does not affect premium. Name Date of birth Sex Marital status Relationship

Driver status:

Gerald Fry May 28, 1962 Male Single Insured

Rated

Education level: High school diploma or GED

Total residents:

The total number of residents currently residing in your household, including listed drivers, young children, roommates or anyone else living in the home for 60 days or more during the next 12 months. 3

Outline of coverage

2003 CHEVROLET CAVALIER 2 DOOR COUPE

VIN: 1G1JC12F537358900

Garaging ZIP Code: 99206

Primary use of the vehicle: Commute

Limits Deductible Premium

Liability To Others $282

Bodily Injury Liability $25,000 each person/$50,000 each accident Property Damage Liability $10,000 each accident

Personal Injury Protection Rejected --

Underinsured Motorist $25,000 each person/$50,000 each accident 39

Underinsured Motorist Property Damage $10,000 each accident $100 12

$300 hit & run

Total 6 month policy premium $333.00

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Policy Number: 917411103

Gerald Fry

Premium discounts

Policy

917411103 Three-Year Safe Driving, Continuous Insurance: Silver, Online Quote, Paperless, Electronic Funds Transfer (EFT) and Five-Year Accident Free Driving history

Progressive uses driving history to determine your rate. There are no accidents or violations for drivers on this policy.

Risk and tier information

Prior insurance: Yes

Prior insurance carrier: Progressive Insurance Company

Policy number: 914411583

Bodily injury limits: Equal to $25,000/$50,000

Comprehensive claims: 00

Not-at-fault accidents: 00

<docindex><index>APPSIGN</index></docindex>

Policy Number: 917411103

Gerald Fry

Application agreement

Verification of content

I declare that the statements contained herein are true to the best of my knowledge and belief and do agree to pay any surcharges applicable under the Company rules which are necessitated by inaccurate statements. I declare that no persons other than those listed in this application regularly operate the vehicle(s) described in this application. I declare that none of the vehicles listed in this application 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 understand that this policy may be rescinded and declared void if any information that would alter the Company's exposure is omitted or misrepresented with the intent to deceive. I understand that it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denials of insurance benefits.

Notice of information practices

I understand that to calculate an accurate price for my insurance, the Company may obtain information from third parties, such as consumer reporting agencies that provide driving, claims and credit histories. The Company may use a credit-based insurance score based on the information contained in the credit history. The Company or its affiliates may obtain new or updated information to calculate my renewal premium or service my insurance. I may access information about me and correct it if inaccurate. In some cases, the law permits the Company to disclose the information it collects without authorization. However, the Company will not share personal information with nonaffiliated companies for their marketing purposes without consent. Complete details are in the Company’s Privacy Policy, which will be provided with this insurance policy and upon request.

Acknowledgement and agreement

• If I make my initial payment by electronic funds transfer, check, draft, or other remittance, the coverage afforded under this policy is conditioned on payment to the Company by the financial institution. If the transfer, check, draft, or other remittance is not honored by the financial institution, the Company shall be deemed not to have accepted the payment and this policy shall be void.

• If I make my initial payment by credit card, the coverage afforded under this policy is conditioned on payment to the Company by the card issuer. I understand that if the Company is unable to collect my initial payment from the card issuer, the Company shall be deemed not to have accepted the payment and this policy shall be void. I also understand that if I authorize a credit card transaction for any payment other than the initial payment, this policy will be subject to cancellation for nonpayment of premium if the Company is unable to collect payment from the card issuer. The Company is deemed "unable to collect" in the following instances:

(1) when I reach my credit limit on my credit card and the card issuer refuses the charge; (2) when the card issuer cancels or revokes my credit card; or (3) when the card issuer does not pay the Company, for any reason whatsoever, upon the Company's request.

• I acknowledge that insurance prices and products are different when purchased directly from Progressive or through agents/brokers.

• The Company may obtain information, including vehicle history information, from third parties. I understand that this information may affect my policy premium or could result in a policy declination, cancellation, or nonrenewal. Other charges

I agree to pay the installment fees shown on my billing statement that become due during the policy term and each renewal policy term in accordance with the payment plan I have selected. I understand that the amount of these fees may change upon policy renewal or if I change my payment plan. Any change in the amount of installment fees will be reflected on my payment schedule.

I understand that a returned payment fee of $20.00 will be assessed to the balance due on my policy if any check offered in payment is not honored by my bank or other financial institution. Imposition of such charge shall not deem the Company to have accepted the check unconditionally.

<docindex><index>APPSIGN</index></docindex>

Policy Number: 917411103

Gerald Fry

I agree to pay a late fee of $10.00 during the policy term and each renewal policy term when a payment is postmarked more than five days after the premium due date or when the minimum amount due is not fully paid within five days of the premium due date. The amount of this fee may change upon policy renewal. Applicant signature

I represent that I, Gerald Fry, am the person identified as the named insured and the first driver in the Drivers and resident relatives section of this application. I acknowledge and agree to the statements contained within this application. I also acknowledge and agree that by typing my name in the designated boxes on the screen below this form and clicking

"Continue", I am electronically signing this application, which will have the same legal effect as the execution of this document by a written signature and shall be valid evidence of my intent and agreement to be bound by its terms. I understand that my name already appears in the signature line below because I chose to electronically sign this application.

Signature of named insured Date

X Gerald Fry October 10, 2017 . Form 4905 WA (12/15)

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