Sales associate
Resume:
DATE:
RECEIPT OF PAYMENT
POLICY NUMBER: PRODUCER:
DOWN PAYMENT
INSTALLMENT
ENDORSEMENT
PRODUCER SWEEP OF AUTHORIZED ACCOUNT
INSURED CREDIT CARD
INSURED CHECKING ACCOUNT
BANK NAME:
CARD TYPE:
ACCOUNT # ENDING:
TRANSACTIONS
DATE AMOUNT
Producer sweep and insured checking sweep will be submitted the next business day to our bank, this could result in a 1 to 3 day delay in the payment being withdrawn from the account. Payments not honored by your bank may result in no coverage and a NSF charge applied www.savemoneycarinsurance.com
001001-000
CHEAPEST AUTO - CALL CENTER
6528 E. 101ST ST D1 #422
TULSA, OK 74133
SMPR0002375-00
12/07/2023 9:29 AM
X
12/07/2023 $250.38
X
VISA
***8904
Policy #:
Policy Type:
Policy Period:
Insuring Company:
Insured Address:
Insured Name:
PAYMENT SCHEDULE
The payment schedule below provides the Payment Amount and Due Dates. Invoices will be mailed to the address above 15 days prior to your payment due date. If your payment is not received on or before your Due Date this may result in a cancellation of your policy for nonpayment of premium. If your financial institution does not honor your payment, a non-sufficient funds (NSF) fee will be applied to the amount due and your insurance coverage will be cancelled. The following Fees are included on all Installments: Amount Due Due Date
KAYLAH PRYOR SMPR0002375-00
Personal Auto
12/07/2023 - 06/07/2024
Old American Indemnity Company
501 24TH NW AVE APT 501B
NORMAN, OK 73069
BILLING/INSTALLMENT FEE: $10.00
$240.32 12/27/2023
$240.32 01/27/2024
$240.32 02/27/2024
$240.32 03/27/2024
$240.34 04/27/2024
SMCI.OKID.1
Oklahoma Liability Insurance Card
Keep this card
WARNING: Oklahoma state law requires a current copy of the owner's security verification form to be surrendered to the motor license agent or other registering agency upon application or renewal of a motor vehicle license plate.
Oklahoma state law also requires a copy of the owner's security verification form to be carried in the motor vehicle at all times, and produced by any driver of the vehicle upon request for inspection by any peace officer or representative of the Department of Public Safety.
In case of an accident, the security verification form shall be shown upon request of any person affected by the accident. Oklahoma Liability Insurance Card
Keep this card
WARNING: Oklahoma state law requires a current copy of the owner's security verification form to be surrendered to the motor license agent or other registering agency upon application or renewal of a motor vehicle license plate.
Oklahoma state law also requires a copy of the owner's security verification form to be carried in the motor vehicle at all times, and produced by any driver of the vehicle upon request for inspection by any peace officer or representative of the Department of Public Safety.
In case of an accident, the security verification form shall be shown upon request of any person affected by the accident. OKLAHOMA LIABILITY INSURANCE CARD
THIS POLICY PROVIDES AT LEAST THE MINIMUM AMOUNTS OF LIABILITY INSURANCE REQUIRED BY SECTION 7-204 OF TITLE 47 OF THE OKLAHOMA STATUTES FOR THE SPECIFIED VEHICLES AND NAMED INSUREDS AND MAY PROVIDE COVERAGE FOR OTHER PERSONS AND OTHER VEHICLES AS PROVIDED BY THE INSURANCE POLICY. EXAMINE POLICY EXCLUSIONS CAREFULLY. THIS FORM DOES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. INSURANCE COMPANY: OLD AMERICAN INDEMNITY COMPANY · 14675 DALLAS PARKWAY, SUITE 500, DALLAS, TX 75254 · NAIC Number: 11665 · Administered By: SAVE MONEY CAR INSURANCE · 6528 E. 101st, St D1 #422 · Tulsa, OK 74133 TO REPORT A CLAIM: VEHICLE - YEAR - MAKE - MODEL - VIN: AGENT:
POLICY NUMBER:
EFFECTIVE DATE: EXPIRATION DATE:
NAMED INSURED: INCLUDED DRIVERS:
CHEAPEST AUTO - CALL CENTER
6528 E. 101ST ST D1 #422
TULSA, OK 74133
PHONE: 918-***-****
SMPR0002375-00
12/07/2023 06/07/2024
KAYLAH PRYOR
501 24TH NW AVE APT 501B
NORMAN, OK 73069
2012 FORD FUSION 3FAHP0HG5CR444713
Date Printed:
AUTOMOBILE POLICY
OLD AMERICAN INDEMNITY COMPANY
Administered by
NAMED INSURED: PRODUCER:
POLICY NUMBER: POLICY TERM:
COVERAGES AND PREMIUMS – Coverage is provided only if a premium is shown for the indicated coverage. COVERAGE and LIMITS OF LIABILITY
PREMIUM
PER VEHICLE TOTALS
FORMS AND ENDORSEMENTS WHICH APPLY: TOTAL VEHICLE PREMIUM POLICY FEE (FULLY EARNED)
TOTAL PREMIUM AND FEES*
SMCI.OKDec.2 Page 1 of 2
*** IMPORTANT NOTICE REGARDING UNINSURED MOTORIST *** This policy provides uninsured motorist coverage on a "per policy" basis. This means the limit shown above is the most wewill pay for uninsured motorist coverage in any one accident without regard to the number of vehicles you insure on this policy. This policy does not stack or combine uninsured motorist coverage based on the number of vehicles on the policy. You may have the right to pay your automobile insurance premium in installments. We will charge a fee for each installment. You may obtain a copy of your personal auto policy form at www.savemoneycarinsurance.com or by calling us at THIS SUPERSEDES ANY PRIOR DATED DECLARATIONS.
SAVE MONEY CAR INSURANCE · 6528 E. 101st, St D1 #422 · Tulsa, OK 74133· 12/07/2023
KAYLAH PRYOR
501 24TH NW AVE APT 501B
NORMAN, OK 73069
ad3jf0@r.postjobfree.com
CHEAPEST AUTO - CALL CENTER
6528 E. 101ST ST D1 #422
TULSA, OK 74133
PHONE: 918-***-****
CUSTOMERSERVICE@SAVEMONEYCARIN
SURANCE.COM
SMPR0002375-00 12/07/2023 at 9:29 AM to 06/07/2024 at 12:01 AM SMCI_40ED, SMCI-DRV-EXCL
Bodily Injury Liability
VEHICLE 1
$25,000 PER PERSON / $50,000 PER LOSS $293
Property Damage Liability $25,000 PER LOSS $504
Other than Collision Deductibles: V1:$2,000 $137
Collision Deductibles: V1:$2,000 $448
$1,382
$1,382.00
$20.00
$1,402.00
page 1 of 2
Policy Number:
Date Printed:
COVERED AUTOMOBILES –
Coverage is provided only for the vehicle(s) listed below and only if principally parked/garaged at the below listed garaging address. VEH# YEAR/MAKE/MODEL VIN RATING SYMBOLS DISCOUNTS/ VEHICLE USE ASSIGNED DRIVER COMP/COLL SURCHARGES**
VEH# ADDRESS
COVERED DRIVER(S) - Coverage is provided only for the drivers listed below. DRIVER NAME LICENSE/ID # ST/COUNTRY LICENSE/ID STATUS MARITAL STATUS/YDE SURCHARGE POINTS EXCLUDED DRIVER(S)
This policy shall not apply nor accrue to the benefit of any insured or any third party when any vehicle is being used or driven by a person listed below. NAME DATE OF BIRTH RELATIONSHIP TO INSURED
GARAGING ADDRESS – If different than the Mailing Address VEH# TYPE NAME ADDRESS
ADDITIONAL INTERESTS - LOSS PAYEES (LP) /ADDITIONAL INSUREDS (AI) Any loss or damage payable under Part D of this policy for any vehicle listed above shall be paid to the named insured and any loss payee or lienholder shown above for such vehicle, as their interest may appear. SMCI.OKDec.2 Page 2 of 2
**Discount Codes: MC = Multi-Car / TR = Transfer / DDC = Defensive Driver Credit / HO = Homeowner / REN = Renewal / AT = In Agency Transfer EFT = Electronic Transfer / PL = Paperless. SURCHARGES BU = Business Use 12/07/2023
SMPR0002375-00
KAYLAH PRYOR P667143278 OK ACTIVE SINGLE/0 0
1 2012/FORD/FUSION 3FAHP0HG5CR444713 25/32 PL COMMUTE KAYLAH PRYOR TRISTEN MAJOR
page 2 of 2
Managing General Agent for
Old American Indemnity Company
SMCI.OKAPP.3 Page 1 of 5
Oklahoma Automobile Application
POLICY #:
EFFECTIVE DATE:
EXPIRATIONDATE:
NAMED INSURED INFORMATION
NAME(S) MAILING ADDRESS (if different from garage
GARAGE STREET ADDRESS address):
CITY, STATE ZIP
COUNTY
HOME PHONE:
CELL PHONE:
BUSINESS PHONE:
EMAIL:
VEHICLE INFORMATION
# YEAR MAKE MODEL VIN TERR SYMBOL USAGE
LIENHOLDER / ADDITIONAL INTEREST INFORMATION
# LIENHOLDER/ADD’L INTEREST ADDRESS
DRIVERS AND HOUSEHOLD RESIDENTS INFORMATION
(List all drivers in household unless they are excluded) DRIVER NAME RELATION DOB GENDER MARITAL
STATUS
POINTS SR-22 DL
STATE
DL#
SMPR0002375-00
12/07/2023 9:29 AM
06/07/2024 at 12:01 AM
KAYLAH PRYOR
501 24TH NW AVE APT 501B
NORMAN, OK 73069
ad3jf0@r.postjobfree.com
1 2012 FORD FUSION 3FAHP0HG5CR444713 25:32 COMMUTE KAYLAH PRYOR INSURED 08/25/2003 F SINGLE 0 NO OK P667143278 Page 1 of 5
Managing General Agent for
Old American Indemnity Company
SMCI.OKAPP.3 Page 2 of 5
DISCOUNTS AND SURCHARGES
Applicable Discounts
Applicable Surcharges
DRIVING RECORD INFORMATION
The driving record listed below is from the previous 36 months from sources such as loss history reports, MVRs and applicant. DRIVER DATE DESCRIPTION
SR22 INFORMATION
Name State Case #
COVERAGES LIMITS/DEDUCTIBLES AUTO AUTO AUTO AUTO AUTO AUTO Bodily Injury Each Person /
Each Accident
Property Damage Each Accident
Medical Payments Each Person
Uninsured Motorist
Bodily Injury
Each Person /
Each Accident
*** IMPORTANT NOTICE REGARDING UNINSURED MOTORIST *** This policy provides uninsured motorist coverage on a “per policy” basis. This means the limit shown above is the most we will pay for uninsured motorist coverage in any one accident without regard to the number of vehicles you insure on this policy. This policy does not stack or combine uninsured motorist coverage based on the number of vehicles on the policy. Comprehensive
(ACV less ded)
Collision (ACV
less ded)
Rental Reimburse-
ment (day/max)
Total Premium Per Vehicle
Total Premium All Vehicles
SR22 Fee
Policy Fee
Down Payment
Payments of
PL
$25,000
$50,000
$25,000
1
(1)
(1)
(1)
$2,000
$2,000
$293.00
$504.00
$137.00
$448.00
$1,382.00
$1,382.00
$20.00
5
$250.38
$240.32
Page 2 of 5
Managing General Agent for
Old American Indemnity Company
SMCI.OKAPP.3 Page 3 of 5
EXCLUSION OF NAMED DRIVERS & PARTIAL REJECTION OF COVERAGES I understand and agree that this NAMED DRIVER EXCLUSION election shall apply to this policy and any renewal, reinstatement, substitute, amended, altered, modified or replacement policy with this Company unless a named insured revokes this election in writing and we agree to remove the exclusion.
No Coverage is provided for any claim arising from an accident or loss involving a vehicle being operated by an EXCLUDED DRIVER(S). This includes any claim for damages made against any Named Insured, Resident Relative or any other person or organization that is vicariously liable for an accident or loss arising out of the operation of a vehicle by the EXCLUDED DRIVER(S). I also agree that coverage is excluded for any negligence which may be imputed by law arising out of the maintenance, use or operation of a motor vehicle by any EXCLUDED DRIVER(S). I also agree that this NAMED DRIVER EXCLUSION election shall also serve as a rejection of Uninsured Motorist Coverage for any vehicle being operated by an EXCLUDED DRIVER(S). I, the above named insured, do hereby state that if one of the above named excluded persons is my legal spouse, I agree and understand that by signing below, no coverage will be afforded under this policy to the above named excluded person (spouse). Name of Excluded Driver Date of Birth Relationship to Applicant Applicant Signature: Date:
APPLICANT QUESTIONNAIRE
Yes/No Explanation Initial
1. Have all residents in the household age 15 and older been listed on the application?
2. Has any driver who operates your vehicle(s), on a regular basis or infrequent basis, including children away fromhomeNOT been listed on this application?
3. Do the vehicle(s) being considered have a salvage title? 4. Do the vehicles(s) being considered have any major modifications or existing damage?
5. Except for students away at school, do all drivers listed on the application reside within the state for at least 10 months of the year?
6. Is your vehicle garaged or regularly operated, such as commuting, in another state?
7. Are any listed vehicle(s) used for business (other than driving back and forth towork)or delivery purposes? (This includes but not limited tomakingsalescalls,driving to job sites, pizza and newspaper delivery)?
8. Do the driver(s) being considered have a felony conviction or more than 2 misdemeanor convictions in the past 20 years?
9. Has any driver ever suffered from blackouts, seizures, epilepsy, diabetes or any other physical impairments? 10. Are the vehicle(s) titled in your name?
Yes K.P.
No K.P.
No K.P.
No K.P.
Yes K.P.
No K.P.
No K.P.
No K.P.
No K.P.
Yes K.P.
KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 TRISTEN MAJOR
Page 3 of 5
Managing General Agent for
Old American Indemnity Company
SMCI.OKAPP.3 Page 4 of 5
ELECTRONIC COMMUNICATIONS
IherebyagreetoreceivethePersonalAutoPolicy,ConsumerBillofRights and Privacy Policy electronically at the e-mail address I have provided. I can also access the information at any time via the company website with the instructions given to me with my Declarations Page.
Applicant Signature: Date:
STATEMENT OF NO COMMERCIAL USE
Iherebycertifythatthevehicle(s)insuredbythepolicyappliedforarenotusedfor any commercial or business purpose. I will not use my vehicle in thecourseofmyemploymentorwhileIamself-employed. This statement is made for the purpose of inducing the Company to issue the coverage for which I have applied and will form part of the application. Applicant Signature: Date:
APPLICANT’S STATEMENT
In compliance with the Fair Credit Reporting Act, you are hereby notified that an investigative consumer report may be made through personal interviews with neighbors, friends, associates or other persons concerning the character, general reputation, personal characteristics, and mode of living of any person proposed for insurance. Upon written request, additional information as to the nature and scope of their report will be provided. You may request to be interviewed if an investigative consumer report is prepared in connection with this application. You also have a right to receive a copy of the investigative consumer report upon written request. I certify that the answers to all questions in this application are true and correct and I understand, recognize and agree that said answers are given and made for the purpose of inducing the Company to issue a policy for which I have applied. In the event the policy is issued, the Company may declare the policy voidable if any of said answers are false and made with the intent to deceive and materially affect the risk which the Company assumes by issuing the policy.
WARNING: Any person who knowingly, and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony. The coverages, including the offer of additional coverages, were explained to me and I knowingly made the selections on this application. Further, I understand rejection of any coverage above applies with respect to all vehicles now insured under the policy as well as any vehicle which may be covered by the Policy in the future regardless of whether it is owned by me on the date of execution of this instrument. The above-signed rejections will apply to any renewal, additional vehicle endorsement, replacement vehicle endorsement or to other supplemental coverage to the policy.
I further understand that the total premium shown on the first page of this application is the producer's calculation based in part upon the assumption that the information that I have provided regarding my driving record, designation and information concerning other operators of the insured vehicle and their driving records, and the principal location of the insured(s) is accurate and complete. If the Company determines that any such information is inaccurate or incomplete, and if I am notified of any additional premium based on accurate and complete information, I agree to pay such additional premium according to the directions in such notice. This insurance is not effective until this application has been received and approved by the Insurance Company. I also agree that if my premium remittance is not honored by my financial institution, no coverage will be afforded. Applicant Signature: Date:
KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 Page 4 of 5
Managing General Agent for
Old American Indemnity Company
SMCI.OKAPP.3 Page 5 of 5
Icertifythat,tothebestofmyknowledge,allinformationcontainedhereiniscorrectandcomplete,thestatementshereinare those of the applicant, this application and any attachments have in all respects been prepared in accordance with the terms of and the applicant legally signed this application for insurance. I am legally qualified to submit this application for insurance. Agent Signature: Date:
AGENT’S STATEMENT
FRAUD NOTICE TO OKLAHOMA APPLICANTS
WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makesanyclaimforthe proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Applicant Signature: Date:
AUTHORIZATION FOR VEHICLE RELEASE
With regards to Comprehensive and Collision coverage, applicant agrees to give Save Money Car Insurance, and its representatives’ the right of possession or control of applicant’s covered vehicle in the event Save Money Car Insurance elects to remove applicant’s vehicle to a secure, storage free facility after a covered loss. Applicant has signed the Statement of Ownership and Authorization to Release applicant’s vehicle to Save Money Car Insurance or its representatives in the event applicant makes a covered claim under applicant’s comprehensive/collision policy and Save Money Car Insurance elects to remove applicant’s vehicle to a secure, storage free facility. Applicant Signature: Date:
KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 VIRGIL NOAH electronically signed 9:29 AM 12/07/2023 Page 5 of 5
SMCI_40ED
40ED - NAMED DRIVER EXCLUSION
The following endorsement applies only if form number 40ED appears on your Declarations Page. No coverage is provided for any claim arising from an accident or loss involving a vehicle being operated by an excluded person. This includes any claim for damages made against any named insured, resident relative, or any other person or organization that is vicariously liable for an accident or loss arising out of the operation of a motor vehicle by the excluded person. You understand and agree that this Named Driver Exclusion shall apply to this policy and any renewal, reinstatement, substitute, amended, altered, modified or replacement policy with us unless you revoke this election in writing and we agree to remove the exclusion.
In consideration of the premium for which the policy is written, it is agreed that we shall not be liable and no liability or obligation of any kind shall be attached to us for losses or damages sustained after the effective date of this endorsement while any motor vehicle insured herein under is driven or operated by an excluded driver. UMApp11012020
OLD AMERICAN INDEMNITY COMPANY
UNINSURED MOTORIST COVERAGE APPLICATION
OKLAHOMA LAW GIVES YOU THE RIGHT TO BUY UNINSURED MOTORIST COVERAGE IN THE SAME AMOUNT AS YOUR BODILY INJURY LIABILITY COVERAGE. THE LAW REQUIRES US TO ADVISE YOU OF THIS VALUABLE RIGHT FOR THE PROTECTION OF YOU, MEMBERS OF YOUR FAMILY, AND OTHER PEOPLE WHO MAY BE HURT WHILE RIDING IN YOUR INSURED VEHICLE. YOU SHOULD SERIOUSLY CONSIDER BUYING THIS COVERAGE IN THE SAME AMOUNT AS YOUR LIABILITY INSURANCE COVERAGE LIMIT
Uninsured Motorist coverage, unless otherwise provided in your policy, pays for bodily injury damages to you, members of your family who live with you, and other people riding in your car who are injured by: (1) an uninsured motorist, (2) a hit-and-run motorist, (3) an insured motorist who does not have enough liability insurance to pay for bodily injury damages to any insured person. Uninsured Motorist coverage, unless otherwise provided in your policy, protects you and family members who live with you while riding in any vehicle or while a pedestrian. "THE COST OF THIS COVERAGE IS SMALL COMPARED WITH THE BENEFITS!"
Please select from one of the following options for Uninsured Motorist Coverage and sign below: I want the same amount of Uninsured Motorist coverage as my bodily injury liability coverage. I want minimum Uninsured Motorist coverage $25,000.00 per person/$50,000.00 per occurrence.
I want Uninsured Motorist coverage in the following amount:
$ per person/$ per occurrence. I want to reject Uninsured Motorist coverage.
DATE:
THIS FORM IS NOT A PART OF YOUR POLICY AND DOES NOT PROVIDE COVERAGE X
INSURED – MUST BE SIGNED
X
KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 ELECTRONIC SIGNATURE AGREEMENT AND DISCLOSURES
Insured: Policy Number:
Effective Date:
The decision whether to sign documents electronically is yours. Your consent to sign electronically and our agreement to do so covers all transactions, including new business applications, endorsements and renewals that you conduct through Save Money Car Insurance (SMCI) for as long as you remain an insured of SMCI. By signing this document, you agree that you have had all of the coverages explained to you by your agent and that you understand the coverages and coverage limits that you are purchasing or rejecting. It is very important that you understand that by rejecting certain coverages, you and your family will have less protection in the event of an accident. In some cases, your agent may assist you in the electronic signature (DocuSign) process, as necessary, by affixing your electronic signature in order to facilitate the transaction. If you DO NOT want to sign documents electronically, do not sign this document and tell your agent that you decline the electronic process, and SMCI will provide an option for you to do business with a pen and paper. By consenting to electronic signature, you agree that your signature and initials will be an electronic representation of your signature and initials for all purposes when you (or your SMCI Agent whom you authorize) use them on documents, including legally binding contracts - just the same as a pen-and-paper signature or initial. By signing this document, you are confirming to us that you agree to all the terms above and consent to sign documents electronically with SMCI.
Signature Of Insured Date
Signature Of Agent Date
KAYLAH PRYOR SMPR0002375-00
12/07/2023
KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023 VIRGIL NOAH electronically signed 9:29 AM 12/07/2023 LETTER OF COMPLIANCE
Insured: Policy Number:
Effective Date:
Expiration Date:
An Oklahoma-compliant liability policy has been issued through Old American Indemnity Company (NAIC # 11665) and administered by Save Money Car Insurance.
The policy is currently in effect for the listed vehicle(s). Signature Of Agent Date
KAYLAH PRYOR SMPR0002375-00
12/07/2023
06/07/2024
3FAHP0HG5CR444713 2012/FORD/FUSION
VIRGIL NOAH electronically signed 9:29 AM 12/07/2023 14675 DALLAS PARKWAY, SUITE 500 · DALLAS, TX 75254 Payment Disclosure Form and Text Agreement
I, (Card Holders Name) do hereby authorize Save Money Car Insurance to process the payment of $ to the card ending in .(last four of the card number used to pay for the policy).
I understand this payment is non-refundable. This payment does include reimbursement for processing charges for obtaining motor vehicle records, obtaining photos for inspection, electronic mail costs, sending electronic documentation, and telephone transmission for services provided. I consent that the amount charged today has been fully disclosed & explained to me by the company. I understand any additional reinstatements, endorsements or new policies may result in additional fees charged bt the company. We have authorized confirmation of this transaction with supporting information of an IP address, customer signature captivated, validated email address, and phone number used to complete this transaction.
Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. By signing, I give Save Money Car Insurance authorization to contact me via phone, email, or text. I understand standard text message rates will apply. I understand I can opt-out of these texts at any time.
Signature Date
KAYLAH PRYOR
250.38 ***8904
KAYLAH PRYOR electronically signed 9:29 AM 12/07/2023
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