Application For Private Passenger Automobile Liability Insurance - Texas Automobile Insurance Plan Association

APPLICATION FOR PRIVATE PASSENGER AUTOMOBILE LIABILITY INSURANCE – TEXAS AUTOMOBILE INSURANCE PLAN ASSOCIATION

P.O. Box 149144, Austin, Texas 78714-9144 • 1120 S. Capital of Texas Hwy., CityView Bldg. 3, Ste. 105, Austin, Texas 78746-6464

(512) 444-4441

Toll Free: (866) 321-9154

APPLICATION MUST BE COMPLETED AND SUBMITTED IN DUPLICATE

Co. Use Only – Policy No.

TDI ID / License No.

Last

First

Middle

Mailing Address

Apt. No.

City

State

Zip Code

County of Residence

Telephone (Incl. Area Code)

(

)

Residence Address (If different from Mailing Address)

Apt. No.

City

State

Zip Code

Is applicant a

resident of Texas?

Yes

No

COMPLETE FOR ALL OPERATORS AND RESIDENTS

Driver’s License No. or Permit Number

Applicant And Other Residents

Relationship

Principal

Veh.

Birth Date

Sex

M/S*

If Not Licensed,

State

Employer/Occupation

14 Years of Age and Over

To Applicant

Operator

No.

Mo.

Day

Yr.

M - F

Explain Why In Space Below

APPLICANT

APPLICANT

Yes

No

SPOUSE

Yes

No

Yes

No

*M/S – Marital Status S – Single M – Married W – Widowed D – Divorced

REASON NOT LICENSED

Veh.

Year

Make

Model Name / Body Type / CC for Motorcycle

Rate Class

Year

Make

Model Name / Body Type / CC for Motorcycle

Rate Class

2

Vehicle Identification Number

Vehicle Identification Number

Est. Annual Mileage

Est. Annual Mileage

Business

Farm

Miles to Work/School

Business

Farm

Miles to Work/School

Pleasure

Work/School

One Way _______________________

Pleasure

Work/School

One Way _______________________

Garaging County Name if not County of Residence

Garaging Zip if not Garaged in County of Residence

Garaging County Name if not County of Residence

Garaging Zip if not Garaged in County of Residence

Territory

State Reg. In

Vehicle Registered To

License Plate #

Territory

State Reg. In

Vehicle Registered To

License Plate #

A. Are there any autos in your household?

Yes

No

If “YES”, does the owner of the auto(s) have insurance on the auto(s)?

Yes

No

If “YES”, what is the insurance company(ies) name and policy number(s)? ____________________________________

If “YES”, are you or your spouse an excluded driver under the owner’s insurance policy on the auto(s)?

Yes

No

B. Are you furnished any autos for regular use?

Yes

No

If “YES”, does the owner of the regularly furnished auto(s) have insurance on the auto(s)?

Yes

No

If “YES”, what is the insurance company(ies) name and policy number(s)? ____________________________________

If “YES”, are you or your spouse an excluded driver under the owner’s insurance policy on the auto(s)?

Yes

No

C. Will the business duties of you or your spouse involve the use of a motor vehicle, other than driving to or from work?

Yes

No

If “YES”, does the owner of the vehicle have insurance on the vehicle?

Yes

No

If “YES”, are you or your spouse an excluded driver?

Yes

No

Name of insurance company providing the coverage ___________________________________________________

D. Named Non-Owner Classification __________________________________________________________________

LIMITS OF LIABILITY

PREMIUM 1

PREMIUM 2

Bodily Injury $30,000 EACH PERSON / $60,000 EACH ACCIDENT / Property Damage $25,000

PERSONAL INJURY PROTECTION COVERAGE – Limit of $2,500 – (Chapter 1952.152 Insurance Code)

PASSIVE RESTRAINTS?

I ACCEPT

Personal Injury Protection on the vehicle(s) described in this application and on each

Driver Only Veh. # ______

I REJECT

renewal thereafter including any additional vehicle(s) added to this assignment.

Both Sides Veh. # ______

B.I.

P.D.

B.I.

P.D.

UNINSURED/UNDERINSURED MOTORIST COVERAGE – (Chapter 1952.101 Insurance Code)

ANY EXISTING DAMAGE?

I ACCEPT

Bodily Injury and Property Damage Uninsured/Underinsured Motorist Coverage on

YES

Veh. # ______

I REJECT

this application and on each renewal thereafter.

NO

Veh. # ______

B.I.

B.I.

Bodily Injury Uninsured/Underinsured Motorist Coverage ONLY and REJECT Property Damage

IF YES IS INDICATED ABOVE,

I ACCEPT

Uninsured/Underinsured Motorist Coverage on this application and on each renewal thereafter.

EXPLAIN IN REMARKS.

IF APPLICANT HAS REJECTED ANY OF THE COVERAGES OFFERED ABOVE, THEY MAY BE ADDED AT ANY TIME BY MAKING WRITTEN REQUEST AND PAYING THE SPECIFIED PREMIUM.

Is applicant

or spouse

required to file or maintain proof of financial responsibility (SR22) with any state?

YES

NO

If “YES”, give the following information in full:

Name ____________________________________________________________________________ Give reason for suspension or required filing ____________________________________________________________________________

State requiring SR22 ________________________________ Date of conviction _________________________________ End of filing period _________________________________ T.D.P.S. File No. __________________________________

Is any other filing required to comply with (a) Any state? ___ YES ___ NO (b) Local Ordinance? ___ YES ___ NO If “YES”, state (a) Type of filing __________________________________________________________________________

(b) List states and cities requiring such filings and limits of liability required. ______________________________________________________________________________________________________________________________________

Gross Annual Premium $ _____________________

The insurer may deduct from your deposit premium any unpaid premium

8 Payment Installment Option

owed to the insurer by you for a prior assigned policy issued by the insurer

Required Down Payment $ _____________________

Advance Premium Payment

during the twelve months immediately preceding the effective date of the

Full Annual Premium

Burglary/Theft Fee $ _____________________

policy. If the deposit premium is 20% or more inadequate, the insurer may

bill for the deficiency immediately.

Premium Finance Co. –

Amount Submitted $ _____________________

Signed P.O.A. Agreement must accompany application.

Check/Money Order No. payable to TAIPA

_____________________

THIS APPLICATION, INCLUDING REVERSE SIDE, MUST BE FULLY COMPLETED.

TAIPA 1000 (01/2013)