Application For Private Passenger Automobile Liability Insurance - Texas Automobile Insurance Plan Association Page 2

Was there prior insurance on the listed vehicle(s) within the last 30 days?

YES

NO

If “YES”, name of Insurance Co. ____________________________________________________________________________________________________________________________ Termination Date ____________________________

Was coverage through the Texas Automobile Insurance Plan Association?

YES

NO Was 3-year assignment completed?

YES

NO

If “NO”, Reason for Termination ________________________________________________________________________________________________________________________________________________________________________

Are any other vehicles owned by any member of household?

YES

NO

If “YES”, give name of Insurer __________________________________________________________________________________________________________

Has the applicant, as OWNER or OPERATOR, or anyone who usually drives the vehicle(s) been involved in a motor vehicle accident, resulting in damage to any property of another, or in bodily injury or death during the 36-month period

immediately preceding the date of this application?

YES

NO If “YES”, complete the following:

NAME OF DRIVER

PLACE OF ACCIDENT

DATE OF ACCIDENT

EXCEPTION NO.*

1.

2.

3.

4.

5.

*Exceptions – If involved in an accident:

1.

which occurred while the motor vehicle owned or operated by the applicant or other person who usually drives the applicant’s motor vehicle was lawfully parked, standing or stopped; or

2.

in which motor vehicle was struck by hit-and-run driver, if such accident was reported to the proper authority within 24 hours; or

3.

as a result of which applicant or other person who usually drives the applicant’s motor vehicle obtained a judgment against, or a settlement from or on behalf of, the owner or operator of another vehicle involved in such accident if the judg-

ment or settlement was obtained prior to the date of application or in case of renewal, prior to the effective date of the renewal policy, and provided no judgment was obtained against or any amount paid in settlement by or on behalf of the

applicant or other person who usually drives the applicant’s motor vehicle as a result of such accident; or

4.

in connection with which neither the applicant nor other person who usually drives the applicant’s motor vehicle was convicted of a moving traffic violation and the owner or operator of another vehicle involved was so convicted; or

5.

resulting in the payment of a personal injury protection loss only.

Has the applicant or anyone who usually drives the vehicle(s) been convicted of (or if a minor under seventeen years of age, been charged with) any offense arising out of the operation of any motor vehicle, except those excluded under the rule for

surcharges applicable to the Texas Automobile Insurance Plan Association, during the 36-month period immediately preceding the date of this application?

YES

NO If “YES”, complete the following:

NAME OF DRIVER

PLACE OF VIOLATION

DATE OF CONVICTION

TYPE OF VIOLATION

1.

2.

3.

4.

5.

REPORTS

APPLICANT authorizes the Insurer to which this application is assigned to obtain motor vehicle reports from any jurisdiction maintaining a record on the applicant or any member of the household. In addition to routine verification of information

pertinent to the insurance applied for, if the application is by an individual for insurance primarily for personal or family purposes, the insurer to which it is assigned may have an investigative consumer report made including information bearing on

character, general reputation, personal characteristics or mode of living and, upon the individual’s written request, will disclose in writing the nature and scope of the investigation requested, if such a report is procured.

APPLICANT – YOUR SIGNATURE ON THIS APPLICATION CERTIFIES THE FOLLOWING (DO NOT SIGN WITHOUT READING)

The APPLICANT hereby certifies that within 60 days prior to the date of application, the Applicant has been rejected for automobile insurance by at least two insurers licensed to do business in Texas and actually writing automobile liability insurance

in Texas, including insurers that are not rate regulated. The Applicant further certifies that the information given in this application is true to the best of the Applicant’s belief. The Applicant hereby agrees to pay all premiums when due and designates

the individual shown below as Producer for this insurance. The Applicant certifies that this application was written and signed on the date shown. If this application is assigned to an insurer operating under Ch. 942, Texas Insurance Code (Reciprocals),

the Applicant agrees that this application shall be taken as an application for membership in that Reciprocal and accepts all filings required by law to be made with the Texas Department of Insurance.

The Producer has offered and explained the 8 payment installment option available through the Texas Automobile Insurance Plan Association.

Premiums shown are estimates. The actual premium will be determined in accordance with approved rates and rating plans and current motor vehicle report information.

________________________________________________________/_______/_______

_________________________________________________________/_______/______

(APPLICANT’S SIGNATURE)

(DATE)

(JOINT APPLICANT’S SIGNATURE)

(DATE)

THIS APPLICATION DOES NOT CONSTITUTE A BINDER OF INSURANCE. COVERAGE BECOMES EFFECTIVE ONLY IN ACCORDANCE WITH THE TERMS OF THE PLAN OF

OPERATION OF THE TEXAS AUTOMOBILE INSURANCE PLAN ASSOCIATION.

The PRODUCER hereby certifies that within 60 days prior to the date of application, the Applicant has been rejected for automobile insurance by at least two insurers licensed to do business in Texas and actually writing automobile liability insurance

in Texas, including insurers that are not rate regulated. The Producer has READ the Plan of Operation, and EXPLAINED the Personal Injury Protection Coverage, Uninsured/Underinsured Motorist Coverage and the 8 Payment Installment Option.

The Producer has included in this application all required information given to the Producer by the Applicant. In the event the policy is cancelled or insurance thereunder terminated, resulting in a return premium to the insured, the Producer agrees

to return the unearned commission.

_________________________________________________________________________

________________/________________/________________

(PRODUCER’S SIGNATURE)

(DATE)