P O Payment Plan
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Policy and premium information for policy number
Agent:
Insurance Company:
TOOLEY & CARVER INSURANCE
P O BOX 660
LAFAYETTE, TN 37083-0660
410499
Named Insured(s): CAMERON HARRIS
LAFAYETTE, TN 37083
305 MAIN ST
LAFAYETTE, TN 37083
Garaging Address: 305 MAIN ST
Tuesday, May 30, 2023 12:42:00 PM CST
Total Policy Premium: $713.00
Initial Payment Received: $178.25
$534.75
Payment Plan: 25.00% Down - 5 Pay
Drivers and Household Residents
Outline of Coverage
Trexis Insurance Corporation
P.O. Box 682322
Franklin, TN 37068
***************@*****.***
Home: 615-***-****
Thursday, November 30, 2023 12:00:00 AM CST
Effective Date and Time:
Expiration Date and Time:
Unpaid Balance:
Mailing Address:
The applicant, spouse, and all household residents 15 years of age or older, all regular operators of the vehicles described in this application, and all children who live away from home who drive these vehicles, even occasionally, are listed below. Contact Information:
Mobile: 615-***-****
Your insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown for a vehicle may not be combined with the limits for the same coverage on another vehicle.
Name Date of Birth Sex Marital Status Relationship Driver Status CAMERON HARRIS M Single Named Insured Rated 1FAHP3HN0AW277008
Garaging Zip Code: 37083
2010 Ford FOCUS SEL
VIN:
Application for Insurance
Please review and sign where indicated. Policyholder: CAMERON HARRIS May 30, 2023
Policy Number: 11-41-019******
11 PA TN AP (6/19) Page 1 of 6
Subtotal Policy Premium $698.00
Total 6 Month Policy Charges $713.00
A fully earned installment of $10 per Direct Bill Invoice sent, or $6 per Recurring Credit/Debit Card draft, or $6 per EFT draft will be charged, in addition to the policy charges shown above.
Limits Deductible Premium
Liability To Others
Bodily Injury $50,000 Per Person/$100,000 Per Occurrence $204.00 Property Damage $50,000 Per Occurrence $391.00
Uninsured Motorists Bodily Injury $50,000 Per Person/$100,000 Per Occurrence $47.00 Uninsured Motorists Property Damage $200 $43.00
Medical Payments $2,000 Per Person $13.00
Total Premium for 2010 Ford FOCUS SEL $698.00
Policy Fee $15.00
Driver History
Trexis uses your driving history to determine your rate. Driver Description Date Source Disputed
CAMERON HARRIS Improper Passing Mar 17, 2023 MVR
CAMERON HARRIS Minor Oct 27, 2022 MVR
CAMERON HARRIS Speeding Jul 30, 2021 MVR
CAMERON HARRIS Improper Passing Jun 5, 2020 MVR
Prior Insurance and Underwriting Questions
No prior insurance selected
Applicant Questionnaire
1. Have all the household residents 15 years of age or older, all regular operators of the vehicles described in this application, and all children who live away from home who drive these vehicles, even occasionally, been disclosed in the “Drivers and Household Residents” section?
(If no, please list.)
Yes No
2. Is the garaging address listed on the application the same for all drivers?
(If no, please explain below.)
Yes No
3. Does any driver listed on the application reside outside the state of Tennessee for more than 2 months per year?
(If yes, you are not eligible for this insurance.) Yes No
4. Is the garaging address listed on the application correct for all vehicles to be insured on the policy? (If no, please explain below.) Yes No
5. Are any of your vehicles used for delivery, limousine or taxi service, for courier or escort service, or for commercial pick up or delivery purposes, including but not limited to delivery of magazines, pizza, food, mail, newspaper or farm produce? Policyholder: CAMERON HARRIS
May 30, 2023
Policy Number: 11-41-019******
11 PA TN AP (6/19) Page 2 of 6
5.
but not limited to delivery of magazines, pizza, food, mail, newspaper or farm produce?
(If yes, you are not eligible for this insurance.) Yes No
6. Are any listed vehicles used in the course of any driver's business or occupation, other than driving back and forth to work?
(If yes, please explain below.)
Yes No
7. Are there other vehicles in your household not listed on this application?
(If yes, please give the vehicle, driver and vehicle insurer.) Yes No
8. Are there any listed vehicles with pre-existing damage?
(If yes, please explain below.)
Yes No
9. Have you or any other driver or household resident listed on this application provided transportation services through or registered to provide transportation services through a Transportation Network Company; mobile device-based ridesharing service or other platform within the last three(3) years? (If so, you are not eligible for insurance with Trexis.)
Yes No
Application Agreement
Verification of Content
I have read, reviewed and understand my entire application. I hereby declare that the statements, representations and promises made herein are true. 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. I understand that my statements, representations and promises become a part of my contract. I also understand and agree that if I have omitted or provided any information that is false, misleading, inaccurate and/or would affect the Company’s decision to accept the risk, provide the limits or coverages requested, or provide the coverages at the premium charged, the Company may, in its sole discretion: reject my application; charge an increased premium for which I will be responsible; or, declare the policy or any renewal policy void from inception. I understand that it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. I acknowledge that this application was fully and completely explained to me by an authorized Trexis agent of my own choosing. 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. I may request that my credit information be updated or that the Company reevaluate my insurance based on corrected credit information from a consumer reporting agency. 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 non-affiliated 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. I Affirm That
All my vehicles insured for Other Than Collision and Collision must be inspected by a representative of Trexis within seven (7) days from the effective date of this policy.
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 a 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 void. 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. Agent Compensation Disclosure
The insurance producer that sold you this policy is a licensed insurance agent authorized by Trexis and by other insurance companies to solicit business on their behalf. We will pay your agent a commission for placing your policy with us. Your agent may also be eligible for additional compensation, based upon the volume and profitability of certain business he or she places with us. Policyholder: CAMERON HARRIS
May 30, 2023
Policy Number: 11-41-019******
11 PA TN AP (6/19) Page 3 of 6
I represent that I am the person identified as the Named Insured and am listed in the Drivers and Household Residents section of this application. I acknowledge and agree to the statements contained within this application. Applicant Signature
Other Charges
I acknowledge and agree to pay the 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. I understand that a Service Charge of $25.00 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 understand that a fully earned $15.00 Policy Fee will be charged for each new and renewal policy. Additionally, a fully earned installment fee of $10.00 per Direct Bill invoice sent, or $5.00 per Recurring Credit/Debit Card draft, or $5.00 per EFT draft will be charged. I also understand that, if applicable, my policy may be charged a Reinstatement Fee of $10.00, a Late Fee of $10.00 or a Financial Responsibility Fee of $20.00. I understand that my acknowledgement of a Reinstatement Fee does not obligate the Company to reinstate coverage following a cancellation lapse. I understand that motor vehicle records will be ordered before my policy is issued. If there are additional accidents or violations, they will be charged for and/or this policy may be canceled. I also understand that if the application does not meet the acceptability requirements of the selected program, the policy could be issued at a higher rate.
I agree to report any and all claims directly to the Company immediately after they occur. Policyholder: CAMERON HARRIS
May 30, 2023
Policy Number: 11-41-019******
11 PA TN AP (6/19) Page 4 of 6
Signature of Named Insured Date
X
Producer Signature
The undersigned hereby warrants and certifies that the information contained herein is correct to the best of his/her knowledge; that this application was fully and completely explained to the Named Insured; that this application was completed and then signed by the Named Insured; that a completed copy has been given to the Named Insured; and that the undersigned will retain a copy hereof. Signature of Producer Date
X
Policyholder: CAMERON HARRIS
May 30, 2023
Policy Number: 11-41-019******
11 PA TN AP (6/19) Page 5 of 6
5/30/2023 12:44:38 PM
Policyholder: CAMERON HARRIS
May 30, 2023
Policy Number: 11-41-019******
11 PA TN AP (6/19) Page 6 of 6
Due Date Payment
05/30/2023 $178.25
06/30/2023 $116.95
07/30/2023 $116.95
08/30/2023 $116.95
09/30/2023 $116.95
10/30/2023 $116.95
*PLEASE NOTE: The payment amounts listed are based on the information provided. Any discrepancies may impact the installment amount shown on this schedule.
Payment Schedule
Franklin, TN 37068
877-***-**** PO Box 682322
Policy Number: 11-41-019******
Policyholder: CAMERON HARRIS
May 30, 2023
INSURED Copy
Agency Payment Receipt Form Trexis Insurance
Corporation
877-***-**** * P.O. Box 682322
Franklin, TN 37068-2322
Payment Method CREDIT Credit Card No. xxxxxxxxxxxx5217 The payment indicated below was received in this agency at the date and time indicated. 8936233 Insured's Name CAMERON HARRIS Policy Number 11-41-019****** Payment Amount $178.25 Transaction ID:
Agency Name TOOLEY & CARVER INSURANCE Agency Code 410499 Agent's Signature Date 5/30/2023 Time 12:42:02 PM CT Down Payment Due With Application (including optional products) Total Premium $174.50
Policy Fee $3.75
Total Due With Application
Total Amount Paid: $178.25
$178.25
VIN: 1FAHP3HN0AW277008
Trexis Insurance Corporation
P.O. Box 682322
Franklin, TN 37068-2322
POLICY NUMBER: 11-41-019******
YEAR: 2010 MAKE: Ford MODEL FOCUS SEL
AGENT: TOOLEY & CARVER INSURANCE
PHONE: 615-***-****
THE INSURED SHALL KEEP A COPY OF THE INSURANCE CARD IN EACH MOTOR VEHICLE COVERED BY THE POLICY.
VIN: 1FAHP3HN0AW277008
Trexis Insurance Corporation
P.O. Box 682322
Franklin, TN 37068-2322
YEAR: 2010 MAKE: Ford MODEL FOCUS SEL
AGENT: TOOLEY & CARVER INSURANCE
PHONE: 615-***-****
THE INSURED SHALL KEEP A COPY OF THE INSURANCE CARD IN EACH MOTOR VEHICLE COVERED BY THE POLICY.
EFFECTIVE: 5/30/2023 TO: 11/30/2023
EFFECTIVE: 5/30/2023 TO: 11/30/2023
TENNESSEE IDENTIFICATION CARD
TENNESSEE IDENTIFICATION CARD
NAIC #: 12188
NAIC #: 12188
INSURED:
INSURED:
DRIVER:
DRIVER:
CAMERON HARRIS
305 MAIN ST
LAFAYETTE, TN 37083
CAMERON HARRIS
305 MAIN ST
LAFAYETTE, TN 37083
CAMERON HARRIS
CAMERON HARRIS
POLICY NUMBER:
ONE CARD MUST BE KEPT IN THE VEHICLE
AND PRESENTED UPON REQUEST
Report all accidents to The Trexis insurance companies as soon as possible: 877-***-****
In case of an accident, please obtain the following information: 1) Name, address and phone number of
each driver, passenger, and witness.
2) Name of Insurance Company and policy
number for each driver/vehicle involved.
THIS POLICY MEETS THE MINIMUM STATE
FINANCIAL RESPONSIBILITY LAW.
ONE CARD MUST BE KEPT IN THE VEHICLE
AND PRESENTED UPON REQUEST
Report all accidents to The Trexis insurance companies as soon as possible: 877-***-****
In case of an accident, please obtain the following information: 1) Name, address and phone number of
each driver, passenger, and witness.
2) Name of Insurance Company and policy
number for each driver/vehicle involved.
THIS POLICY MEETS THE MINIMUM STATE
FINANCIAL RESPONSIBILITY LAW.
Franklin, TN 37068-2322
877-***-**** * P.O. Box 682322
Trexis Insurance Corporation
Insurance Identification Cards
Franklin, TN 37068-2322
877-***-**** * P.O. Box 682322
Trexis Insurance Corporation
Insurance Identification Cards
Trexis has a long history of protecting the privacy of its customers. This notice describes the personal information we collect about you and how we use and protect it. It applies to our current policyholders who live in your state and replaces any earlier version that we may have provided you.
What information is collected?
We collect information about you to quote and service your policy. This is typically called “Nonpublic Personal Information” if it identifies you and is not available to the public. Depending on the product, we collect it from some or all of the following sources. Not all examples may apply specifically to your policy. Application Information – You provide this on your application through your agent. We also obtain it from other directories or outside sources. It includes your name, street and email addresses, phone numbers, driver’s license numbers, social security numbers, date of birth, gender, marital status, types of vehicle, and information about other drivers.
•
Consumer Report Information – We obtain this from consumer reporting agencies. It includes your driving record, claims history with other carriers, and credit report information. The information is kept by the consumer reporting agencies and disclosed to them by others only as permitted by law.
•
Transaction Information – This includes your insurance coverages, policy limits, and payment and claims history. It also includes information that we require for billing and payment.
•
Website Information – This information is unique to internet transactions. It includes the pages you view on our site, and your computer operating system. Some websites, including ours, may store “cookies” on your computer. Cookies collect technical data like your IP address, operating system, and session ID. They can also save certain information entered by you. Some of our websites contain specific privacy notices. Please read these when using those sites.
•
How is information shared?
We will share information about you only as permitted by law. We will not share your Nonpublic Personal Information with other companies for their marketing purposes without your consent. There is no need to “opt out” or tell us not to do this. Disclosures include those we feel are required to provide insurance claims or customer service, prevent fraud, perform research, or comply with the law. Recipients include, for example, claims representatives, service providers, and consumer reporting agencies, insurance agents, law enforcement, courts and government agencies. These parties may disclose this information to others as permitted by law. For example, consumer reporting agencies may disclose transaction information received from us to other insurance companies with which you do business. How can information be reviewed and corrected?
To review information we have about you, send a written request to Trexis Customer Service, PO Box 682322 Franklin, TN 37068. You must describe the information you wish to review and state that your request is in response to this Privacy Policy. Include your full name, mailing address, and policy or claim number (if applicable). Within 30 business days, we will describe what is available and how you may request corrections. We will also name anyone we show as having received the information within two years of your request. Finally, we will identify the companies that have provided consumer report information about you. We will not provide information we feel is privileged, such as information about insurance claims or lawsuits. To correct information about you, send a written request detailing your desired correction. Within 30 business days, we will either make the requested correction or tell you why we cannot. We cannot correct consumer report information, such as your credit report. To do this, you must contact the consumer reporting agency that provided it. If we make your requested correction, we will notify you in writing. We will also notify anyone named by you who may have received the information within the previous two years. If required by law, we will also notify others who may have given it to or received it from us. If we refuse to make the requested correction, you may file with us a statement detailing why you object, including the information you think is correct. Your statement will then become part of your file. It will be sent to the same group that we would send a copy of any correction or change. Our family of insurance companies
This notice is from our family of insurance companies. As of the date of this Privacy Policy, this includes: Trexis One Insurance Corporation and Trexis Insurance Corporation.
Privacy Policy
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