COLORADO AUTO INSURANCE APPLICATION

AAAA Insurance Company

N PO Box 24524, Oakland, CA 94623-1524
T Telebind: (800) 207-3801 Underwriting (800) 207-3618 Underwriting Fax (866) 711-3186

) MAY CAUSE ANY POLICY ISSUED TO BE CANCELED AND CLAIMS TO BE DENIED.

Program Selection: AAA Insurance Policy Type: Regular Tier: G
Named Insured (First MI Last) Primary/Garaging Address: Producer Code: 9331 Phone #: (970) 245-2236

Information
DON WELCH Agency Name, Address: x3842

Agency
Colorado - Grand Junction Office
16236 E PURDUE PLACE 4100 E. Arkansas Ave.
AURORA CO 80013
Denver , CO 80222
Insured Information

Residence: Other Producer: Eve Owens

E-mail: [email protected]
Mailing Address: Policy Number:
Same As Primary/Garaging Address
Policy Effective Date: 10/1/2010 Time: 12:01 AM

Policy Information
Policy Upload Date: Not uploaded yet Time:
Telebind #:
Home Phone #: (303) 862-8853 Work Phone #: Policy Term: 6 Months
E-mail: Previous AAA Policy Number:
SS#: XXX-XX- Member #:
Occupation: UNEMPLOYED Financial Responsibility Filing Information
Employer’s Name: Dr#: Type: Case#: Issued By:
Address:
All residents and dependents of your household age 15 and older must be listed on this application. Also, any other regular
operators must be listed. Any person may be excluded from coverage except the first named insured, or an individual requesting an
SR22 filing from AAA Insurance.
DR Driver Name Relation to Marital Living w/ Driver’s License
Age DOB Sex
Driver, Dependent, and Resident Information

# Exactly as Shown on License Applicant Status Spouse State/Number

1. DON WELCH Named Insd 58 5/9/1952 Male Single N/A HI / H00099699
2.
3.
4.
5.
6.
7.
8.
9.
DR License Date First Drvr
Driver Status ADB Prev Lic SR22 Driver Discounts Driver Surcharges
# Status Licensed Type
1. YRated
N No US 05/1968 N/A No P
2. Y N
3. Y N
4. Y N
5. Y N
6. Y N
7. Y N
8. Y N
9. Y N
The following is a complete list of all ACCIDENTS, COMP CLAIMS GREATER THAN $1000, AND TRAFFIC CONVICTIONS
for all drivers in the past 33 months. All accidents are considered “At Fault” unless proof is provided showing “Not At Fault”
(Police Report, CLUE Report or other Carrier’s payment).
Driving & Claim History

DR Total
Incident Date Incident Date Incident Date Incident Date
# Points

Policy Number Applicant Name: DON WELCH Page: 1 of 4

AA11CO 05 09
 Veh Vehicle
Year Make Model VIN Salvage Usage
# Type
1. 1996 SUZUKI X-90 UTIL 4X4 Auto JS3LB11S5T4101868 No Pleasure
2.
3.
4.
Phys
Motor Vehicle Information

Veh Garage Geog. Stat Stated Date

Dam Vehicle Discounts Vehicle Surcharges
# Zip Code Factor Code Amount Purchased
Symbol
1. 80013 80013 AC 23 1/1/0001
2.
3.
4.
Veh
Loss Payee or Additional Insured Name & Address (Financial Institution Only) or Certificate Holder LP AI CH
#

All additional, optional, or special equipment not installed by the original manufacturer must be included on the application.
Total not to exceed $6000 per vehicle without prior approval, or no coverage bound. The physical damage deductibles for
Comp & Coll will apply.
Veh
Item Description – Make/Model/ID # Required Value Purchase Date
Special Equipment

The Vehicle Identification Number(s) have been verified on the vehicle AND registration. Y X N
Inspection

Agent has inspected all vehicles requesting physical damage coverage AND taken required photographs. Y N X
Agent’s

No existing damage was present other than the damage detailed below.
Veh#: Damage: Veh#: Damage:
Veh#: Damage: Veh#: Damage:

Prior Carrier: Farmers Alliance Cos Prior Policy #: Months Insured: 12

Days Lapse: 0 Prior Liability Limits: 25/50
Total Household Comp Claims > $1000: Total # Not-at-Fault Accidents For All Rated Drivers:
Policy Discount & Surcharge

Assoc. Name: Membership #:

AAA HO/Renters policy #: AAA Motorcycle policy #:
Has Named Insured or Spouse had more than one cancellation for non-payment on an AAA Insurance policy
Information

Y N
within 36 months?
AAA Term Life, Whole Life, Universal Life or Annuity? Y N X
If yes, AAA Life policy #:
Policy Discounts Policy Surcharges

AAA MEMBER, ADVANCE SHOPPING, LOYALTY

Policy Number: Applicant Name: DON WELCH Page: 2 of 4

AA11CO 05 09
 1. 1.Is the
Is the Named
Named InsuredInsured the registered
the registered ownerowner of all vehicles
of all vehicles on theon the policy?
policy? If No,
If No, list wholist whotheir
is and is and their
relationship. Y Y XNN
2. Arerelationship.
any owned vehicles not insured with AAA Insurance? If yes, please explain. Y N X
3. 2.AreAre
anyany
drivers,
owned dependents,
vehicles notor residents
insured withexcluded from coverage?
AAA Insurance If Yes, Ifcomplete
Company? the Named Driver Exclusion
Yes, explain. Y Y NN X
Form.
3. Are any drivers, dependents, or residents excluded from coverage? If Yes, complete the Named Driver Y NN X
4. Are any vehicles used for delivery purposes, such as pizza or newspaper delivery, or for any other commercial use? If Y
Yes,Exclusion.
the risk is unacceptable.
4. Are any vehicles used for delivery purposes, such as pizza or newspaper delivery, or for any other
5. Are any vehicles used in your business or occupation? Coverage is void during business or artisan use unless such Y Y NN X
usecommercial
is indicated.use? If Yes, the risk is unacceptable.
6. 5.HaveAre anylicensed
ALL vehicles used
and in your business
unlicensed residents or of occupation?
your household, Coverage
age 15 andvoidolder
during business
including or artisanbeen
roommates use Y Y XNN
unless on
disclosed such
thisuse is indicated.
application?
7. 6.HaveHave
ALLALL licensed
drivers, such and unlicensed
as children awayresidents
from home, of your
or in household,
College, who age
may 14operate
and older
yourincluding
vehicle onroommates
a REGULAR or Y Y XNN
been disclosed
INFREQUENT basis,on thislisted
been application?
on this application?
8. 7.DoesHave
anyALL
driverdrivers, such
currently as achildren
have suspendedawayorfrom home,
revoked or in College, who may operate your vehicle on a
license? Y Y NN X
Underwriting Information

9. Have REGULAR
you lived or INFREQUENT
at your basis,less
present address been thanlisted on this
1 year? application?
If yes, list the previous address. Y N X
10.8.Is any
Doescarany driver
rebuilt, currently have
customized, a suspended
altered, or salvaged? or revoked license? Y Y NN X
11.9.Does anyyou
Have car have
lived existing damage,address
at your present including broken
less thanglass?
1 year? If yes, list the previous address. Y Y NN X
12. Has the applicant’s credit information been adversely impacted by a dissolution of marriage within the past seven Y N X
10.yearsIs any car
or by therebuilt,
credit customized,
information ofaltered,
a former orspouse?
salvaged? Y N
11. Does any car have existing damage, including broken glass? Y N
12. Has the applicant’s credit information been adversely impacted by a dissolution of marriage within the past Y N
seven years or by the credit information of a former spouse?
Underwriting Comments or Remarks

Coverages Limits Premiums

Vehicle Coverages: Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Liability – BI/PD: 25/50/50 $189.00
Med Pay: NO COV
UM – PD Ded: 1: NO COV
Comp Ded: 1: NO COV
Coverages, Premiums and Payment Plan Information

Coll Ded: 1: NO COV

Spec Equip: 1: N/A
Rental Reimb: 1: NO COV
Towing 1: NO COV
Car Loan/Lease NO COV
Auto Death Ben:

Subtotal Each Vehicle: $ 189.00

Total Vehicle Coverages Premium:
General Policy Coverages: Limits: Premiums:
UM / UIM– BI: 25/50 $22.00
Total General Policy Coverages Premium:
SR22 Fee(s): $0.00
Total Policy Premium: $211.00
Pay Plan Information Payment Plan: Basic Pay Monthly - 28% Down Pay Method:
Down Pay Required: $ 59.08 (28%) Down Pay Remitted: $ 59.08
# Payments Required: 4 Payment Including Installment Fee: $42.98

Down Payment Information

Policy Number: Applicant Name: DON WELCH Page: 3 of 4

AA11CO 05 09
 FRAUD WARNING
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.
An insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the
department of regulatory agencies.

APPLICANT’S SIGNATURE Read carefully before signing.

I have read all of the above application for a AAA Insurance Company (“Company”) Auto Policy and I hereby warrant that the
statements contained herein are true and complete to the best of my knowledge and belief. I agree to pay any surcharges applicable
under Company rules which are necessitated by inaccurate statements.
This application is submitted to Company with the knowledge that it will be used as the factual basis for the decision of Company
to insure, or not to insure me. By signing the application, I acknowledge that I am aware that if at any time it is discovered that any of
the statements of fact contained in the application are false, or a material fact is omitted or misrepresented, the policy may be
rescinded and declared void and claims denied at the sole option of Company.
All coverages and optional coverages, including Special Equipment Coverage and Uninsured Motorist Property Damage Coverage,
were explained to me and I fully understand them. I knowingly make the coverage selections indicated.
I fully understand and agree that coverage is bound no earlier than the time and date the application is electronically bound in
Company’s system and the application is signed by both me and an agent or is bound over the telephone by my voice signature. I
agree that if I pay my initial premium by check, the coverage afforded by this policy is conditioned on the check being honored by the
bank when presented for payment. If the check is not honored, it will be deemed non-payment of the premium, and no coverage will
have been bound, or afforded under this application and subsequent binder or policy. Signing this application does not bind Company
to complete the insurance.
I understand that a service charge of $20.00 will be assessed to the balance due on my policy if my bank does not honor any
check or electronic draft offered in payment. Imposition of such charge shall not deem Company to have accepted the check or
electronic draft unconditionally.
Any portion of this application filled out by an agent is expressly acknowledged to have been done at my request. I acknowledge
that I have received a copy of this application. I agree to inform Company of any changes in condition (address, drivers, vehicles,
and/or use) within 10 days of such change, and to accept the resulting premium adjustment.
I understand and agree that as part of Company’s policy issuance procedure, Company may obtain consumer reports (which may
include credit information) or personal or privileged information from third parties. A routine inquiry will be made to obtain
underwriting, claims and driving record information for all drivers of the vehicle(s) being insured. I authorize Company to obtain such
information and direct state motor vehicle authorities to release information at Company’s request to the full extent permitted by law.
Subsequent reports may be used for an update, renewal or extension of my insurance.

Signature of Named Insured-Applicant X _________________________________________________ Date________________

Signature of Parent or Legal Guardian X _________________________________________________ Date________________

AGENT SIGNATURE

I hereby warrant and certify that the information contained herein is correct to the best of my knowledge; that I have asked the
applicant and recorded his/her answer to all questions on this application; that this application was completed and then signed by the
insured-applicant; that a completed copy hereof has been given to the insured-applicant; that I have a duplicate signed copy hereof;
that I am legally qualified to submit this application on behalf of the applicant.

Signature of Producing Agent X____________________________________________ Date:___________ Time: ___________

Policy Number: Applicant Name: Page:

DON WELCH 4 of 4
AA11CO 05 09
 AAA Insurance Company PO Box 24524 Oakland, CA 94623-1524 (800)207-3618 E
-
(800) 207-3618
Policy Number: Effective Date: 10/1/2010

Named Insured: DON WELCH Agent Number: 9331

MEDICAL PAYMENTS
REJECTION OF COVERAGE

PERSONAL AUTO

I have been offered Medical Payments Coverage in the amount of $5,000 and I reject this coverage.

I understand and agree that this rejection of Medical Payments Coverage shall be binding on all
persons insured under the policy, and that this shall also apply to any renewal, reinstatement, substitute,
amended, altered, modified, or replacement policy with AAA Insurance unless a named insured submits a
request to add the coverage and pays the additional premium.

Signature of Named Insured-Applicant X___________________ Date:_______________

AA16CO 08 09 INSURED COPY