Management Services Baton Rouge
Resume:
GoAuto Insurance Company (A Stock Company)
Administered by GoAuto Management Services, LLC
Application for Personal Automobile Insurance
GoAuto Insurance Company Page 1 of 3
GAIC 2.00 TX (2020-08)
Policy Number: Quote Number:
Location: Effective Date/Time:
Sales Person: Expiration Date/Time:
Quoter: Process Date/Time:
APPLICANT: PRODUCER:
GoAuto Management Services, LLC
533 Highlandia Dr. Suite A
Baton Rouge, Louisiana 70810
NAMED INSURED, OTHER APPLICANT DRIVERS, and other HOUSEHOLD MEMBERS Including EXCLUDED PERSONS (if any).
Name DOB Gender MS Relation Drv's Lic Date Licensed Pts SR-22 Occupation Dr Status R=Rated Driver, E=Excluded Person, V=Excluded from Specific Vehicle(s) VEHICLE INFORMATION
Year Make Model Body Type VIN Number Sym Cost New Use
LIENHOLDERS:
EXISTING DAMAGE AND OTHER NOTES:
Home Office
12/02/2023 11:46
armstead, pamela r.
2775 spindletop square apt 113
Beaumont, TX 77703
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New Quote
New Quote
12/02/2023 11:46
06/02/2024 00:01
2019 Jeep Compass trailhawk Utility Vehicle - Four Whee 3C4NJDDB3KT671027 23 N/A Personal 2019 Jeep:
LIENHOLDER: CPS Inc P O Box 57071 Irvine CA 92619
pamela r. armstead 05/29/1967 Female S Self 16579184 TX 06/24/83 0 R DOROTHY ARMSTEAD 06/06/1942 Female M 07/06/42 0 E
*176851995AP01*
GoAuto Insurance Company Page 2 of 3
GAIC 2.00 TX (2020-08)
RATES, COVERAGES, AND DISCOUNTS
Driver
Vehicle
Coverage:
PREMIUM AND FEES
Premium
Policy Fee
Other Fees
Policy Total Term: Premium is refundable but fees are fully earned and NON-REFUNDABLE. APPLICANT STATEMENTS
Applicant: check the appropriate true/false box below next to your answer to the question. TRUE FALSE
My spouse and I are the registered owners of each listed vehicle on this application Each listed vehicle on this application is permanently garaged at the address provided No vehicle on this application is primarily parked on the street I am aware that this policy does not pay for equipment or accessories that are not manufacturer installed No vehicle listed on this application is used; in the course of my employment, or for the purpose of conducting my business, for delivery (pizza delivery), to transport goods or persons for hire, as a contractor, electrician, plumber, carpenter, welder, heating or air conditioning worker, or any other service business
I have been instructed to read my policy thoroughly and completely
“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."
30/60 $290.00
2019 Jeep
Middle-Market
pamela r. armstead
LIBI
LIPD 25 $259.00
UMBI None
UMPD None
MED None
COLL $1,000 Deductible $340.00
COMP $1,000 Deductible $104.00
TOWING None
RENT None
PIP None
Transfer 15%
993.00
51.00
2.00
1,046.00 Semi-Annual
*176851995AP02*
8
8
8
8
GoAuto Insurance Company Page 3 of 3
GAIC 2.00 TX (2020-08)
Applicant's Disclosure and Classification of All Persons Living in the Applicant's Household I, the applicant, acknowledge that I have been asked to provide the names of all persons living in my household, whether licensed or not and whether or not they are related to me. I affirmatively state that I have fully and truthfully disclosed this information. I understand that this information may affect; whether the policy is issued, the premium charged for the risk; whether the policy would be subject to any different terms, conditions or exclusions. I understand that my policy may be voided if I fail to truthfully disclose, to the insurance company or its agent, the names of all persons living in my household with the deliberate intention to deceive or defraud the insurance company. Each person listed on this application will be classified as one of the three following categories: I. Covered Person: A person that lives in my household, and that I have been asked underwriting questions about that person that I have truthfully answered, and a premium has been calculated and charged. 2. Excluded Person: A person that lives in my household, I have requested be excluded from coverage and I have signed the Named Driver Exclusion Endorsement form that excludes this person from any coverage in this policy. I may request that any person, living in my household, be an Excluded Person if, by agreement between myself and the insurance company, I sign a Named Driver Exclusion Endorsement form that excludes the listed person or persons from any coverage in this policy.
3. Excluded Person from a Specific Vehicle: A person that lives in my household that I have requested be excluded from coverage on a specific vehicle, and I have signed the Named Driver Exclusion Endorsement form. I acknowledge that as a condition of my insurance coverage, I have a duty to notify the insurance company in writing, within 30 days, of any person who is not already listed on this application that becomes a resident of my household. My notification to the insurance company will provide the name, driver's license, driving history, or any other underwriting information the insurance company requests about the new resident of my household. Covered Person(s):
Excluded Person(s):
Excluded Person(s) from Specific Vehicle(s):
Applicant’s Signature Date
APPLICANT'S STATEMENT
I declare that I have read this application and provided all the information requested by the company. I attest that all information provided is complete, true and accurate. By my signing this agreement, I am asking the insurance company to issue the requested insurance policy and renewals thereof in reliance on the provided information. I am aware that obtaining information about me and all covered persons listed on this application may be required, such as; driving and loss history, credit information, and insurance score. I authorize and give my approval to the insurance company and/or its managing general agent to obtain and use this information as part of this application process and any renewal of this policy being issued.
Applicant’s Signature Date
pamela r. armstead
DOROTHY ARMSTEAD
*176851995AP03*
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