P M Payment Plan
Resume:
Form_SCTNID_CTGRY.FL********_APPLICAT
<docindex><index>APPSIGN</index></docindex> BDF_AA
Policy Number: 979414512
Policyholder:
Daniel Drake
April 1, 2024
Application for Insurance
Please review and sign where
indicated
Policy and premium information for policy number 979414512
Insurance company: Progressive Select Insurance Co PO Box 31260
Tampa, FL 33631 . Named Insured: Daniel Drake
8971 Jefferson Ave
Jacksonville, FL 32208
Producer name and number: Mark Pesich Number: P143434
Financial responsibility vendor: EXPERIAN
Policy period: Apr 1, 2024 - Oct 1, 2024
Effective date and time: Apr 1, 2024 at 03:23 P.M. Total policy premium: $694.00
Initial payment required: $51.43
Initial payment received: $51.43
Payment plan: 6 payments
Drivers and household residents
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You and your spouse
All household residents 15 years of age or older
All regular drivers of the vehicles listed in this application All children who live away from home who drive these vehicles, even occasionally All persons who are titled owners of the listed vehicles, other than those who are not household members and do not operate any listed vehicle
The following are listed below:
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. Date of birth: Gender:
Marital status: Relationship:
Driver status:
Daniel Drake
Aug 28, 1943 Male
Single Insured
Rated
License type: Operator - Personal Auto
Education level: High school diploma or GED
Occupation: Retired (full-time)
Date of birth: Gender:
Marital status: Relationship:
Driver status:
James Drake
Jul 4, 1969 Male
Single Child
Rated
License type: Operator - Personal Auto
<docindex><index>APPSIGN</index></docindex> BDF_AA Policy Number: 979414512
Daniel Drake
Outline of coverage
2014 CHEVROLET IMPALA 4 DOOR SEDAN
VIN: 2G1WD5E3XE1140429
Garaging ZIP Code: 32208
Primary use of the vehicle: Pleasure
Annual miles: 4,000 - 5,999
Length of vehicle ownership when policy started or vehicle added: At least 1 month but less than 6 months This vehicle is currently enrolled in the Snapshot® Program.
Limits Deductible Premium . Liability To Others
Bodily Injury Liability $10,000 each person/$20,000 each accident $256
Property Damage Liability $10,000 each accident 306 . Uninsured Motorist Rejected -- . Personal Injury Protection/Deductible applies to $10,000 $1,000/person 132 Named Insured/Spouse/Dependent Resident Relatives Work Loss Excluded
Total 6 month policy premium $694.00
Premium discounts
Policy
979414512 Continuous Insurance: Silver, Online Quote, Paperless, Home Owner, Online Signature - First Policy Period Only and Automatic Card Payments (ACP)
Vehicle
2014 CHEVROLET
IMPALA
Snapshot Participation, Driver and Passenger-side Airbag and Anti-Lock Brakes Driving history
Please review the following information carefully because driving history is used to determine your premium. All accidents are considered at-fault and over any applicable payment threshold unless we receive additional information from you or another source that proves otherwise. We obtain driving and claims history from one or more of the following sources:
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Your application (APP)
Progressive claims history (PROG)
Motor Vehicle Reports and/or court data (MVR) - provided by a consumer reporting agency Comprehensive Loss Underwriting Exchange (CLUE) - provided by a consumer reporting agency
Driver: Daniel Drake
Description: at fault accident
Date: Oct 31, 2023
Source/Consumer reporting agency: APP, CLUE/LexisNexis, MVR/LexisNexis
Driver: Daniel Drake
Description: failure to yield
Date: Oct 31, 2023
Source/Consumer reporting agency: APP, MVR/LexisNexis
Underwriting information
Prior insurance: Yes
Prior insurance carrier: Other / I don't know
Policy number: 000************
Bodily injury limits: Greater than or equal to $250,000/$500,000 or $300,000 CSL
<docindex><index>APPSIGN</index></docindex> BDF_AA Policy Number: 979414512
Daniel Drake
Personal Injury Protection (PIP) Notice of Cost Savings Options For personal injury protection insurance, the named insured may elect a deductible and to exclude coverage for loss of gross income and loss of earning capacity ("work loss"). These elections apply to the named insured only, or to the named insured and all dependent resident relatives. A premium reduction will result from these elections. You are hereby advised not to elect the "work loss" exclusion if the named insured or dependent resident relatives are employed, since lost wages will not be payable in the event of an accident. Your Personal Injury Protection selections are shown under the "Outline of coverage" section of this application.
<docindex><index>APPSIGN</index></docindex> BDF_AA Policy Number: 979414512
Daniel Drake
Application agreement
Verification of content
I represent that the statements contained herein are true to the best of my knowledge and belief. I declare that I have disclosed all persons required to be disclosed in the "Drivers and household residents" section of 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, except for rideshare use of any such vehicle for which Progressive Rideshare Insurance has been purchased. I understand that this policy may be rescinded and declared void if this application contains any materially false information or if any information that would alter the Company's exposure is omitted or misrepresented. If the policy is not rescinded and declared void, I agree to pay any surcharges applicable under the Company rules, which are necessitated by corrections to the policy due to my inaccurate statements. Acknowledgement and agreement
• All household residents 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, have been disclosed in the
"Drivers and household residents" section. I have described any business or commercial use of my vehicle(s) on this application.
• If I pay my initial premium by check, draft, or other remittance, the coverage afforded by this policy is conditioned on the check, draft, or other remittance being honored by the bank or other financial institution when presented for payment. Other remittances do not include credit card payment. If a 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 from inception unless the nonpayment is cured within the earlier of: 1. five (5) days after I receive actual notice by certified mail; or 2. fifteen (15) days after notice is sent to me by certified or registered mail.
• 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.
• Each vehicle listed in this application is garaged at the same location in the ZIP code provided in this application more than 50% of the time.
• I acknowledge that insurance prices may vary based on how I buy (e.g., mobile, tablet, phone, agent, etc.).
• 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 interest charges 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 interest charges may change upon policy renewal, any policy change, or a change in my payment plan. Any change in the amount of interest charges will be reflected on my payment schedule. I agree to pay a late fee of $10.00 during the policy term and each renewal policy term when either the minimum amount due is not paid or payment is postmarked more than 5 days after the premium due date. The amount of this fee may change upon policy renewal.
<docindex><index>APPSIGN</index></docindex> BDF_AA Policy Number: 979414512
Daniel Drake
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. The Department of Financial Services offers free financial literacy programs to assist you with insurance-related questions, including how credit works and how credit scores are calculated. To learn more, visit www.MyFloridaCFO.com.
Insured initials
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Signature of Named Insured Date
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<Anchor>NamedInsd_Signature</Anchor> <Anchor>NamedInsd_Sign_Date</Anchor> Per Florida Statute 817.234(1)(b), any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Form 4905 FL (09/22)
April 1, 2024
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