Nashville Tn Property Damage

SUMMARY OF CHANGE(S)

$ $

$

$

$ : Pro-rata increase or decrease

$ $

: Next Payment Amount

: Optional Down Payment : Current Payment Due Date

: Current Term Premium

: New Term Premium

: Term Premium Difference

: Current Payment Amount

: Next Payment Due Date

:#Payments Remaining

PREMIUM & BILLING

Agency Name:

Policy Number:

Effective Date of Change:

Effective Time of Change:

Named Insured:

$

: Endorsement Fee

PO Box 305054, Nashville TN 37230

Generated at 03:05:50 PM CDT, 06/07/2024, User: NTCSLL31/NTCSLL31 Policy Change

Request (Quote

Only)

06/07/2024

3:05 PM

JERRY THOMPSON

1G-OH-7047131 (quote 2553979)

THE GENERAL AUTO INS SVCS OH (998878)

862.00 109.79

945.00 07/04/2024

83.00 10

79.74

0.00

7.00

06/04/2024

Insured signature required for ANY reduction and/or deletion of coverage PERMANENT GENERAL ASSURANCE CORPORATION

•

•

•

Policy Change Down Payment

By paying the amount of $19.94

you will help reduce your future premium payments to 107.80. Was call from the NI or spouse and recorded? Yes

Endorsement Status and Instructions

What's the next step?

At this point you may...

return to the request overview page and request an instant quote. make additional changes or corrections to the request details. cancel this request entirely.

Discount Changes:

No Changes in Discounts

State:

COVERAGE CHANGES

SIGNATURE OF NAMED INSURED DATE

Date of Birth Drivers License # State

VEHICLE CHANGES

Gender

PI039-0603-OH (E)

Custom

Equipment

Marital

Status SR-22

Towing

and Labor

Rental

DRIVER CHANGES

City: Area: Zip Code:

Agency Name:

Policy Number:

ADDRESS CHANGES

Driver

Transaction Relation

New Address:

Named Insured:

Year Make/Model

Address

LIENHOLDER / ADDITIONAL INTEREST CHANGES

City, State, Zip

Lienholder

Transaction Year Make/Model LP AI

Insured signature required for ANY reduction and/or deletion of coverage Name

Driver Name

(as shown on license)

Vehicle

Transaction

X

Primary Phone: Alternate Phone:

Social Security #

Number

Comp Collision

Ded Ded Reimbursement

PO Box 305054, Nashville TN 37230

Medical Payments Uninsured Motorist

Liability Bodily Injury - Property Damage Uninsured/Underinsured Property Damage Accidental Death Motorist Bodily Injury

Generated at 03:05:50 PM CDT, 06/07/2024, User: NTCSLL31/NTCSLL31 Policy Change

Request (Quote Only)

06/07/2024

3:05 PM

JERRY THOMPSON

1G-OH-7047131 (quote 2553979)

THE GENERAL AUTO INS SVCS OH (998878)

Change (1) THOMPSON, JERRY NI 04/27/1982 RW066367 OH M S Y 9162 Signature not required Signature not required

PERMANENT GENERAL ASSURANCE CORPORATION

X

X

PA039-0603-OH (E)

SIGNATURE OF NAMED INSURED DATE

EXCLUDED DRIVER RELATION/GENDER

EXCLUDED DRIVER EXCLUDED DRIVER

EXCLUDED DRIVER

DRIVER EXCLUSIONS

SIGNATURE OF NAMED INSURED DATE

I ACKNOWLEDGE THAT UNINSURED MOTORIST PROPERTY DAMAGE COVERAGE HAS BEEN MADE AVAILABLE TO ME. I VOLUNTARILY AND KNOWINGLY CHOOSE TO REJECT UNINSURED MOTORIST PROPERTY DAMAGE COVERAGE. Named Insured:

Policy Number:

Agency Name:

ACKNOWLEDGEMENT AND REJECTION OF UNINSURED MOTORIST PROPERTY DAMAGE COVERAGE

Effective Date of Change:

Effective Time of Change:

RELATION/GENDER

RELATION/GENDER

RELATION/GENDER

DATE OF BIRTH

DATE OF BIRTH

DATE OF BIRTH

DATE OF BIRTH

E X C L U D E D D R I V E R R E L A T I O N / G E N D E R DATE OF BIRTH E X C L U D E D D R I V E R RELATION/GENDER DATE OF BIRTH X X

BUSINESS USE EXCLUSION

I CERTIFY THAT I DO NOT USE MY VEHICLE IN THE COURSE OF BUSINESS AND/OR DELIVERY. IT IS MY DUTY TO NOTIFY MY AGENT IN THE EVENT AN INSURED VEHICLE MAY,SUBSEQUENTLY, BE USED FOR BUSINESS. MY AGENT HAS FURTHER EXPLAINED ACCEPTABLE AND NON-ACCEPTABLE BUSINESS USAGE.

SIGNATURE OF APPLICANT DATE SIGNATURE OF SPOUSE, IF APPLICABLE DATE X

SIGNATURE OF SPOUSE, IF APPLICABLE DATE

PO Box 305054, Nashville TN 37230

Nothing herein contained shall be held to alter, vary, waive or extend any of the terms, conditions, agreements or limits of the undermentioned policy other than as stated herein below.

In consideration of the premium for which the policy is written, it is agreed that the Company shall not be liable and no liability or obligation of any kind shall be attached to the Company for losses or damages sustained after the effective date of this endorsement while any motor vehicle insured under this policy is driven or operated by any below listed individual(s). I understand and agree that this driver exclusion endorsement shall be binding on all persons insured under this policy, and that this exclusion shall apply to any renewal, reinstatement, substitute, amended, or replacement policy, unless the named insured submits a request in writing to change or modify the existing driver exclusion(s) on this policy.

Generated at 03:05:50 PM CDT, 06/07/2024, User: NTCSLL31/NTCSLL31 Policy Change

Request (Quote

Only)

06/07/2024

3:05 PM

JERRY THOMPSON

1G-OH-7047131 (quote 2553979)

THE GENERAL AUTO INS SVCS OH (998878)

Signature not required

Signature not required Signature not required

Signature not required Signature not required

PERMANENT GENERAL ASSURANCE CORPORATION

Agency Name:

Policy Number:

Named Insured:

PO Box 305054, Nashville TN 37230

Generated at 03:05:50 PM CDT, 06/07/2024, User: NTCSLL31/NTCSLL31 Policy Change

Request (Quote

Only)

06/07/2024

3:05 PM

JERRY THOMPSON

1G-OH-7047131 (quote 2553979)

THE GENERAL AUTO INS SVCS OH (998878)

PERMANENT GENERAL ASSURANCE CORPORATION

Additional Policy Details

Policy Change Down Payment

By paying the amount of $19.94

you will help reduce your future premium payments to 10 payments of $107.80. Actual Policy Change Down Payment: $0.00

Driver 1 - THOMPSON, JERRY

Are all household residents age 14 and older, whether licensed or unlicensed, listed or excluded on this policy? Yes Are all persons that may regularly or occasionally drive a vehicle listed or excluded on this policy? (Example: military, college students, etc.)

Yes

Have all vehicles registered in the household been added to the policy? Yes License status: Active

Are all household residents age 14 and older, whether licensed or unlicensed, listed or excluded on this policy? Yes Are all persons that may regularly or occasionally drive a vehicle listed or excluded on this policy? (Example: military, college students, etc.)

Yes

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