Form_SCTNID_CTGRY.XX****WELCOMELTR_COVERLTR

$ ***67 INS WELCOME POLWHITEFONT FLBIJ5K2WICNEZWTRYE735BFLA0001 RPUID TRACWHITEFONT Underwritten by:

January 23, 2019

Progressive Preferred Insurance Co

JOSHUA JENSEN

THE ARIZONA GROUP

1125 E. Southern Avenue

Mesa, AZ 85202

Arnold M Ruiz

995 S Main Dr

Apache Junction, AZ 85120

Dear Arnold M Ruiz,

Thank you for contacting me about your motorcycle insurance needs. Progressive is the largest motorcycle insurer in the country, with claims offices in all 50 states. Claims service is available 24 hours a day, 7 days a week. Please send the requested information by February 8, 2019. Enclosed you will find:

• Your application. Please review and sign where indicated.

• Policy documents that require your signature.

Required initial payment for the policy

Based on the payment options we discussed, a minimum initial payment is required. Coverage does not begin until your minimum payment, signed application and signed policy documents have been received in my office. To receive billing reminders, payment confirmations, and more, visit progressiveagent.com. Then log on to "Manage Your Policy" and click on "E-mail Preferences". Except for your agent, we will not share your e-mail address with other companies for their marketing purposes without your consent. Convenient e-mail service for ad4b62@r.postjobfree.com

If you have any questions, please call me at 1-480-***-****. DocuSign Envelope ID: 7FDCD2A1-697E-467B-B0DA-4195343A6DF1 Form_SCTNID_CTGRY.AZ0117CHECKLIST_COVERLTR

$ 24067 INS CHECKLST POLWHITEFONT FLBIJ5K2WICNEZWTRYE735BFLA0002 RPUID TRACWHITEFONT Policyholder:

Arnold M Ruiz

Page 1 of 1

Provide the following information

Please review the items listed below and return the requested information to my office as soon as possible. Your quoted insurance premium is based on the information you provided on the application. If we do not receive the items requested, your quoted insurance premium may change. Coverage does not begin until the application and applicable policy documents have been signed and received in my office, and the minimum initial payment has been submitted. Sign and return

Your application

Uninsured Motorist and Underinsured Motorist Coverage Selection Form Please retain:

Copies of receipts for the Accessory Coverage and photos of the vehicle(s) for your records. These documents will be needed to show proof and value of all accessory coverage in the event of a loss. Return to: JOSHUA JENSEN

THE ARIZONA GROUP

1125 E. Southern Avenue

Mesa, AZ 85202

Fax: 1-480-***-****

Form CHECKLIST AZ (01/17)

DocuSign Envelope ID: 7FDCD2A1-697E-467B-B0DA-4195343A6DF1 Form_SCTNID_CTGRY.AZ05154868_APPLICAT

$ 24067 INS APPLICAT POLWHITEFONT FLBIJ5K2WICNEZWTRYE735BFLA0003 RPUID TRACWHITEFONT Named insured:

Arnold M Ruiz

January 23, 2019

Page 1 of 4

Application for Insurance

Please review, sign where

indicated and return

Policy and premium information

Insurance company: Progressive Preferred Insurance Co PO Box 6807

Cleveland, OH 44101 . JOSHUA JENSEN

THE ARIZONA GROUP

Mesa AZ 85202

1125 E. Southern Avenue

24067

1-480-***-****

,

Agent:

Named insured: Arnold M Ruiz

995 S Main Dr

Apache Junction, AZ 85120

e-mail address: ad4b62@r.postjobfree.com

Home: 1-602-***-****

Work:

Financial responsibility vendor: EXPERIAN

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

Your policy will be effective when your required initial payment is received by your Total policy premium:

Initial payment required:

Payment plan:

$125.00

$125.00

1 payment

agent or at a later date of your choice.

Drivers and household residents

All household residents who operate the vehicles described in the application, all operators that have an ownership interest in any of these vehicles and any other regular operator of these vehicles are listed below. Name Date of birth Sex Marital status Relationship

Arnold M Ruiz Dec 13, 1950 Male Single Insured

License status: Valid

Principal vehicle: 2013 CAN-AM COMMANDER

Education level: Completed some college

4

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DocuSign Envelope ID: 7FDCD2A1-697E-467B-B0DA-4195343A6DF1

$ 24067 INS APPLICAT POLWHITEFONT FLBIJ5K2WICNEZWTRYE735BFLA0003 RPUID TRACWHITEFONT Arnold M Ruiz

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Outline of coverage

2013 CAN-AM COMMANDER CC: 976

VIN: 3JBKGCP10DJ000401

Garaging Zip Code: 85120 State: AZ Use: On-Road/Off-Road

Limits Deductible Premium .

$40

Bodily Injury Liability $100,000 each person/$300,000 each accident Liability To Others

Property Damage Liability $50,000 each accident

Uninsured Motorist $100,000 each person/$300,000 each accident 8 . Underinsured Motorist $100,000 each person/$300,000 each accident 6 . Medical Payments $2,500 each person 5 . 21

Includes Disappearing Deductible

Comprehensive $500

35

Includes Disappearing Deductible

Collision $500

Roadside Assistance 10 . Accessory Coverage $3,000 included . Total premium for 2013 CAN-AM $125

Total 12 month policy premium, with paid in full discount $125 Premium discounts

Policy

Home Owner, Paid in Full, Prompt Payment and Transfer

Driver

Arnold M Ruiz Responsible Driver and Motorcycle Endorsement Driving history

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

Subject to your limits of liability, if you have paid a premium for Comprehensive Coverage or Collision Coverage and you do not have Agreed Value on your motorcycle or off-road vehicle, you will receive coverage for any loss arising from theft or damage to any accessory attached to your motorcycle or off-road vehicle up to $3,000. "Accessory" means equipment, devices, enhancements, and changes, other than those that are original manufacturer installed, which alter the appearance or performance of a covered vehicle.

Please be aware that accessories may have been added to your vehicle by any previous owner, including a dealership. In this event, the cost for any accessory may have been included in the purchase price of the vehicle. If the total value of your accessories exceeds $3,000, you may wish to purchase additional coverage. This coverage is available for an additional premium and affords protection for up to $30,000 worth of accessories. 4

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DocuSign Envelope ID: 7FDCD2A1-697E-467B-B0DA-4195343A6DF1

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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 understand that this policy may be canceled and coverage may be denied for an accident or loss if this application contains any false or fraudulent representations that are material to the risk insured hereunder and that, if the true facts were known to the Company, it would have refused to issue the policy or required the policy to be issued with limitations. The Company will provide liability coverage to the extent required by the financial responsibility laws of the state of Arizona for an accident occurring before any policy is canceled.

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. 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 canceled.

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 canceled. 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 agree that the maximum limit of liability for Comprehensive Coverage and Collision Coverage (if purchased) is the Actual Cash Value of the factory standard vehicle at the time of the loss, unless either of the Total Loss Coverage or Agreed Value Coverage options is selected, in which case the maximum limits are determined as provided for in the policy contract. If I have purchased Agreed Value Coverage, I understand that I must maintain the necessary paperwork (photos, title of vehicle, and all receipts) used in determining the Agreed Value of each vehicle. In the event of a loss, this information will be required to settle a claim.

All physical damage losses, regardless of loss settlement option and whether partial or total, are subject to the applicable deductible.

Other charges

I understand that if I cancel this policy for any reason or the Company cancels it due to my failure to pay any premium when due, any refund due will be computed on a 90% of a daily pro rata basis. This is an accelerated method of calculating earned premium on cancellations. For all other cancellations, any refund due will be computed on a daily pro rata basis.

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DocuSign Envelope ID: 7FDCD2A1-697E-467B-B0DA-4195343A6DF1

$ 24067 INS APPLICAT POLWHITEFONT FLBIJ5K2WICNEZWTRYE735BFLA0003 RPUID TRACWHITEFONT Arnold M Ruiz

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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. I agree to pay a late fee of $5.00 during the policy term and each renewal policy term when either the minimum amount due is not paid or payment is postmarked more than 7 days after the premium due date. The amount of this fee may change upon policy renewal.

Liability coverage limits for household members

If the named insured or any resident relative sustains a bodily injury in an accident, liability coverage under this policy for that bodily injury is limited to $15,000 each person and $30,000 each accident, which is the minimum amount of coverage required by the Arizona Financial Responsibility Act. I have read and understand the coverage limitation as described. Signature of named insured Date

X Form 4868 AZ (05/15)

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Form_SCTNID_CTGRY.AZ08052465_SIGNFORM

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Uninsured Motorist and Underinsured Motorist Coverage Selection form We offer Uninsured Motorist and Underinsured Motorist coverages for your protection. We offer several different limits of liability for these coverages. The available limits and associated premium are shown below. These coverages protect you, your resident relatives and your passengers if injured in an accident and the person responsible has no insurance (an uninsured motorist) or does not have enough insurance (an underinsured motorist). Please review your policy for a full description of these coverages.

You have the right to purchase both Uninsured Motorist Coverage and Underinsured Motorist Coverage with limits from

$15,000 each person/$30,000 each accident (split limits) up to an amount equal to your policy's liability limit, or you may reject these coverages entirely. Neither limit may exceed your liability coverage limits for Bodily Injury. Uninsured Motorist and Underinsured Motorist coverage on a policy listing more than one vehicle may not be stacked, added or combined together to determine the total amount of coverage available due to bodily injury arising from one accident.

Your Bodily Injury Limit on the policy:

Available limits of coverage and the associated premiums are as follows:

$100,000 each person/$300,000 each accident

Uninsured Motorist Coverage

Please check only one coverage option. All other options are rejected by you. Limits Premium

$15,000 each person/$30,000 each accident $3.00

$25,000 each person/$50,000 each accident $3.00

$50,000 each person/$100,000 each accident $5.00

X $100,000 each person/$300,000 each accident $8.00 . I do not wish to purchase Uninsured Motorist Coverage. Underinsured Motorist Coverage

Please check only one coverage option. All other options are rejected by you. Limits Premium

15,000 each person/$30,000 each accident $2.00 .

25,000 each person/$50,000 each accident $2.00 .

50,000 each person/$100,000 each accident $4.00 . X $100,000 each person/$300,000 each accident $6.00

I do not wish to purchase Underinsured Motorist Coverage. I understand and agree that selection of any of the above options shall be binding on all persons insured under the policy, and that this selection shall apply to this policy and any renewal, reinstatement, substitute, amended, altered, modified, or replacement policy with this company or any affiliated company, unless a named insured revokes this selection or selects a different option.

Signature of named insured Date

X Form 2465 AZ (08/05)

DocuSign Envelope ID: 7FDCD2A1-697E-467B-B0DA-4195343A6DF1 1/23/2019

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One Time Payment Authorized for Progressive:

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DocuSign Envelope ID: 7FDCD2A1-697E-467B-B0DA-4195343A6DF1 1/23/2019

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