Buyer Lessor

NOTICE TO BUYER/LESSEE: This Agreement does not authorize the Seller/Lessor to order Public Liability or Property Damage Insurance. Any insurance ordered by the Seller/Lessor or Seller's/Lessor's Assignee will cover loss of or damage to the vehicle and will not include Public Liability or Property Damage Insurance. BUYER'S/LESSEE’S NAME (Printed) ADDRESS

HOME PHONE BUSINESS PHONE

AGREEMENT TO FURNISH INSURANCE POLICY

X

©2017 The Reynolds and Reynolds Company

THERE ARE NO WARRANTIES, EXPRESS OR IMPLIED, AS TO CONTENT OR FITNESS FOR PURPOSE OF THIS FORM. CONSULT YOUR OWN LEGAL COUNSEL. X

FORM NO. 228RS-U_e REV. 7/17 V2

Date

To Seller/Lessor

The undersigned Buyer/Lessee(s) agree(s) to furnish his/their own Insurance Policy, covering a vehicle which is the subject of a credit sale contract/lease dated this day of, YR

The vehicle referred to herein is described as follows: Year Make Model Body Type Vehicle Identification No. Such Insurance Policy must be delivered to the Seller/Lessor within days from the date of this Agreement. The following is not an acceptable policy: Maintenance or repair contracts, One Month Policies or Insurance Certificates that make reference to a “Master Insurance Agreement.” If Seller/Lessor does not receive such Policy by the time stated, Seller/Lessor may (but is not required to) procure insurance of the kind and type agreed to be furnished under the terms of the credit sale contract/lease. Such insurance may cover only Seller’s/Lessor’s interest in the vehicle as the law allows. Ins.Co. Agent

Policy No. Exp. Date

Fire & Theft - Additional Coverage - $ Deductible Comprehensive - $ Deductible Collision In the event Buyer/Lessee(s) fail(s) to furnish a valid insurance policy, or written evidence of insurance, of the type required under the credit sale contract/lease, Buyer/Lessee(s) hereby agree(s) to pay to Seller/Lessor or assignees any earned premium for any policy they may have to place for the above described vehicle in accordance with repayment procedures set forth in the credit sale contract/lease. Buyer/Lessee(s) further agree(s) to assume any and all responsibility for damage to the vehicle or resulting from the use, maintenance or operation of the vehicle, and agree to hold Seller/Lessor free of any loss, claim, or liability resulting from any damage to the vehicle or from the vehicle’s use, maintenance or operation. Loss Payee

Loss Payee’s Address

BUYER'S/LESSEE’S SIGNATURE CO-BUYER'S/CO-LESSEE’S SIGNATURE ADDRESS OF AGENT - STREET CITY STATE ZIP AGENT'S PHONE NUMBER 03/10/2022

KERNERSVILLE CHRYSLER D/J, LLC

950 HIGHWAY 66 SOUTH KERNERSVILLE NC 27284

10th

MARCH 2022

2015 JEEP GRAND CHEROKEE 4DR 4WD 1C4RJFAG5FC942877 GEICO GEICO

ONE GEICO PLAZA WASHINGTON DC 20076 800-***-****

424******-**/11/2022

XX 500.00 XX 500.00

ALLY FINANCIAL

PO BOX 8143 COCKEYSVILLE MD 21030-

EMANISE GEORGES 6 WEDDINGTON CT

336-***-**** 336-***-**** GREENSBORO NC 27407

N/A

BUYER

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