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Company: Permanent General Assurance Corporation

New York Automobile Insurance Application
POLICY NUMBER: NY5620173
POLICY PERIOD: 05/28/21 11:08 AM CDT - 11/28/21 12:01 AM CST
POLICY TERM: 6 MONTHS
APPLICANT INFORMATION PRODUCER INFORMATION
Name MERRI L ANDREANO THE GENERAL AUTO INS SVCS, INC
Address 6263 FURNACE RD PO BOX 305054
ONTARIO, NY 14519-8966 NASHVILLE, TN 37230-5054

Primary Phone (585) 698-4182 Alternate Phone Phone (800) 280-1466

Email Address [email protected] Code 617232
APPLICANT GARAGING ADDRESS (if different from mailing address)

COVERAGE AND LIMITS OF LIABILITY – Coverage applies only where premium is indicated. WARNING: The policy does
not cover loss to equipment not installed by the vehicles original manufacturer unless coverage for equipment is listed below under
Custom Equipment, and there is an additional $50.00 deductible that applies for each claim made for Custom Equipment. Include value
and description for each item.
COVERAGES / LIMITS VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4 VEHICLE 5
Bodily Injury – Property Damage Liability
(Per Person/Per Accident) $306.00
$25,000/$50,000/$10,000
Supplemental Spousal Liability No Coverage
Uninsured Motorist Bodily Injury
(Per Person/Per Accident) $12.00
$25,000/$50,000
Supplementary Uninsured/Underinsured Motorist No Coverage
Medical Payments No Coverage
Personal Injury Protection/Deductible $167.00
$50,000/$200 DEDUCTIBLE
Optional Basic Economic Loss No Coverage
Additional Personal Injury Protection No Coverage
Total Aggregate Personal Injury Protection $50,000 Included
Death Benefits $2,000 Included
Maximum Monthly Work Loss $2,000 Included
Other Necessary Expenses (per day) $25 Included
Rental Reimbursement No Coverage
Towing & Labor No Coverage

Deductible 1000/1000
Comprehensive / Collision
Premium $278.00

Custom Equipment Coverage Amount No Coverage

(Cost New) Premium No Coverage
Premium Sub-Total (per Vehicle) $763.00
SELECTED PAYMENT PLAN MOTOR VEHICLE LAW ENFORCEMENT FEE $5.00
$169.60 DOWNPAY + 4 MONTHLY PAYMENTS TOTAL DOWNPAYMENT/PREMIUM $169.60
FIRST INSTALLMENT OF $176.60 DUE ON 06/17/21. TOTAL $768.00

Visit our self-service website at www.thegeneral.com/mypolicy Fully earned installment fee included: $12.00
THIS APPLICATION BECOMES PART OF YOUR INSURANCE POLICY
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APPLICANT NAME: MERRI L ANDREANO POLICY NUMBER: NY5620173
DRIVERS Complete this section for all persons 16 or older living in your household and all other persons who use your vehicle on a
regular basis.
DATE OF MARITAL RELATIONSHIP TO
DRIVER NAME GENDER
BIRTH STATUS NAMED INSURED
1 MERRI L ANDREANO 04/15/1960 FEMALE DIVORCED NAMED INSURED

LICENSE # LICENSE STATUS LICENSE STATE DATE FIRST LICENSED SOCIAL SECURITY #

1 303314203 ACTIVE NY 04/15/1976 XXX-XX-2417

DRIVING HISTORY Identify all incidents, accidents, license suspensions and expirations during the previous 39 months for all
drivers (include out of state).

DRIVER # DATE DESCRIPTION PTS

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APPLICANT NAME: MERRI L ANDREANO POLICY NUMBER: NY5620173
VEHICLES
VEH # YEAR MAKE / MODEL / STYLE IDENTIFICATION NO. (VIN)

1 2010 FORD / EXPLORER XLT 1FMEU7DE2AUA91349

VEHICLE EXISTING REGISTRATION REGISTERED REGISTERED

VEH # TERRITORY SYMBOL
USE DAMAGE STATE OWNER CO-OWNER
1 14519 PERSONAL 3155050KJ0KP N/A NY DRIVER 1

LIENHOLDER(S) LH = Lienholder AI = Additional Interest

VEH # NAME / MAILING ADDRESS TYPE
1 ONEMAIN FINANCIAL / PO BOX 200049 KENNESAW GA 30156 LH

DISCOUNTS / SURCHARGES
ANTI-LOCK BRAKE DISCOUNT VEH:1
ANTI-THEFT PASSIVE ALARM VEH:1
WINDOW GLASS VIN ETCHING VEH:1

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APPLICANT NAME: MERRI L ANDREANO POLICY NUMBER: NY5620173

GENERAL QUESTIONS NOTES AND SUPPLEMENTS – EXPLAIN ANSWERS

1. Are any vehicles garaged outside the State for more than 60 TIER 3539403937
days a year? _____ THIS APPLICATION INCLUDES THE PURCHASE OF
NO THE FOLLOWING PRODUCT(S) PROVIDED BY NATION
2. Are any vehicles owned by anyone other than a listed driver? SAFE DRIVERS (NSD): 24/7 ROADSIDE
ASSISTANCE. THE FEES FOR THE NSD PRODUCT(S)
_____
NO WILL BE AUTOMATICALLY INCLUDED IN YOUR
3. Are any listed vehicles used to conduct business, or to INSTALLMENT BILL.
perform work or occupational requirements? _____
NO
4. Has the Applicant or Applicant’s spouse been previously
cancelled by the Company for loss experience, convicted of
Insurance fraud/felony in the last 10 years, and/or employed
in illegal enterprise/occupations? _____
NO
5. Are all household residents age 16 and older, whether
licensed or unlicensed, listed on this application? _____
YES
6. Are all persons that may regularly or occasionally drive a
vehicle listed on this application? _____
YES

AUTHORIZATION FOR AUTOMATIC BANK DRAFT OR DEBIT / CREDIT CARD PAYMENT

I, the above named customer, hereby authorize the Company to originate charges to my bank account or debit / credit card for all
payments related to this application for insurance, endorsements or renewal of the same. Either party may terminate this
authorization and payment method at any time upon written notice.

APPLICANT SIGNATURE NOT APPLICABLE DATE ____________________________

SUPPLEMENTAL SPOUSAL LIABILITY INSURANCE COVERAGE

New York State Law requires that upon written request of an insured, and upon payment of the premium, an insurer issuing
or delivering a policy that satisfies the requirements of article 6 of the New York Vehicle and Traffic Law shall provide
Supplemental Spousal Liability Insurance coverage.
Supplemental Spousal Liability Insurance provides bodily injury liability coverage under a motor vehicle insurance policy to
cover the liability of an insured spouse because of the death or injury to his or her spouse, even where the injured spouse
must prove the culpable conduct of the insured spouse.
This coverage, if purchased, is included within the policy’s bodily injury liability limits and does not increase the amount of
those limits. For example:
Insured’s bodily injury policy coverage: $100,000/$300,000
Insured’s bodily injury damage claim paid to spouse: $75,000
Insured’s bodily injury policy coverage limit available to all other claimants subject to a maximum of $100,000 per person:
$225,000
This example assumes the spouse and other claimants involved in the accident have a right to sue the insured for economic
loss or for non-economic loss (i.e., pain and suffering) sustained as a result of a “serious injury” as defined in section 5102 (d)
of the Insurance Law. It must also have been shown that there was negligence on the part of the insured.
The additional premium for Supplemental Spousal Liability Coverage is $12.00. If you do not elect to purchase this coverage
and do not remit the additional premium, Supplemental Spousal Liability Coverage is not included in your motor vehicle
insurance policy.
I confirm by my signature below that I do not want to purchase Supplemental Spousal Liability Coverage.

APPLICANT SIGNATURE X DATE ____________________________

05/28/21 11:08 AM CDT
MERRI L ANDREANO

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APPLICANT NAME: MERRI L ANDREANO POLICY NUMBER: NY5620173

SUPPLEMENTAL UNINSURED/UNDERINSURED MOTORIST COVERAGE (“SUM”)

I understand that I may purchase Supplemental Uninsured/Underinsured Motorist Coverage (“SUM”), and that I may select SUM
limits in an amount equal to but not exceeding the limits of my bodily injury liability coverage.
The coverage and limits selected in this application are options I desire.

APPLICANT SIGNATURE X DATE ____________________________

05/28/21 11:08 AM CDT
MERRI L ANDREANO

OPTIONAL BASIC ECONOMIC LOSS (OBEL) COVERAGE OFFER

Optional Basic Economic Loss (OBEL) coverage is being offered to you as an enhancement of the Basic No-Fault coverage you are
presently required to purchase. But before we describe this coverage, we would like to advise you what benefits Basic No-Fault
coverage does and does not provide.
No-fault coverage, otherwise known as Personal Injury Protection or “PIP” coverage, pays for expenses incurred by persons injured
in a motor vehicle accident. This coverage does not pay to repair damage to your automobile.
Basic No-Fault, which you are required by law to purchase, provides coverage of up to $50,000 per person in benefits for:
1. all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee schedules
established or adopted by the New York State Insurance Department; and
2. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date of accident;
and
3. up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary expenses the
injured person may have incurred because of an injury resulting from the accident, such as the cost of hiring a
housekeeper or necessary transportation expenses to and from a health service provider; and
4. a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for economic loss
described above.
No-fault benefits will be reduced by other benefits that are payable under Workers’ Compensation, Social Security Disability, New
York State Disability, and certain employer “wage continuation” plans where an employee does not lose any future sick leave
benefits.
Optional coverage available
In addition to Basic No-Fault coverage, you may also purchase OBEL coverage that will pay certain expenses, up to $25,000,
above the Basic No-Fault limit of $50,000. OBEL coverage is different from other coverages in that a claimant can select the kinds
of benefits to be paid under OBEL.
If you purchase OBEL coverage and if it appears likely that a claimant will use up the basic No-Fault coverage, your insurer will
send the claimant a form for the claimant to choose what expenses the $25,000 in OBEL coverage will be used to pay. Under No-
Fault, a claimant could include you, family members, passengers in your car, or pedestrians, if injured in an auto accident.
The claimant will be able to choose one of the following four options and thereby direct the insurer to pay expenses for:
1. basic economic loss, whether health care expenses, loss of earnings from work, or other reasonable and necessary
expenses;
2. loss of earnings from work;
3. psychiatric, physical or occupational therapy and rehabilitation; or
4. a combination of option 2 and 3
The additional $25,000 of OBEL coverage will be used only for costs incurred under the chosen option, which, once selected, the
claimant cannot change.
I confirm by my signature below that I do not want to purchase OBEL coverage.

APPLICANT SIGNATURE X 05/28/21 11:08 AM CDT

DATE ____________________________
MERRI L ANDREANO

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APPLICANT OR POLICYHOLDER’S NAME: MERRI L ANDREANO POLICY NUMBER: NY5620173

ACKNOWLEDGEMENT OF REQUIREMENT FOR PHOTO INSPECTION

INSURED NAME: MERRI L ANDREANO
INSURED ADDRESS: 6263 FURNACE RD
ONTARIO, NY 14519-8966

VEHICLE(S) TO BE INSPECTED: EFFECTIVE DATE

# YEAR MAKE MODEL VIN OF COVERAGE
1 2010 FORD EXPLORER XLT 1FMEU7DE2AUA91349 05/28/21

INSPECTION MUST BE COMPLETED BY: 06/11/21

BY MY SIGNATURE BELOW I CERTIFY THAT I HAVE BEEN INFORMED THAT MY VEHICLE(S) WHICH IS/ARE
BEING INSURED FOR COLLISION AND / OR COMPREHENSIVE COVERAGE, MUST BE INSPECTED BY THE
INSURER’S AUTHORIZED REPRESENTATIVE. THIS/THESE INSPECTIONS MUST BE COMPLETED WITHIN (14)
CALENDAR DAYS AFTER THE EFFECTIVE DATE OF COVERAGE, BUT IN NO EVENT LATER THAN THE DATE
SHOWN ABOVE TO AVOID A SUSPENSION IN COVERAGE. I UNDERSTAND THAT FAILURE TO OBTAIN THE
REQUIRED INSPECTION(S) WILL RESULT IN THE SUSPENSION (LOSSES WILL NOT BE COVERED) OF THE
PHYSICAL DAMAGE COVERAGE (COLLISION, COMPREHENSIVE, FIRE, THEFT) AS OF 12:01 A.M. OF THE DAY
FOLLOWING THE DATE THE INSPECTION MUST BE COMPLETED BY.
IF COVERAGE IS SUSPENDED, THEN IT WILL BE RESTORED AFTER THE INSPECTION(S) IS/ARE COMPLETED.
SIGNATURE OF APPLICANT
OR POLICYHOLDER X DATE __________________________
05/28/21 11:08 AM CDT
MERRI L ANDREANO

SIGNATURE OF PRODUCER OR
INSURER’S AUTHORIZED REPRESENTATIVE: 05/28/21 11:08 AM CDT
DATE __________________________

NAME, ADDRESS & TELEPHONE NUMBER OF PRODUCER OR INSURER’S AUTHORIZED REPRESENTATIVE

COMPLETING THIS FORM: THE GENERAL AUTO INS SVCS, INC
PO BOX 305054
NASHVILLE, TN 37230-5054
(800) 280-1466
POLICYHOLDER (APPLICANT) SHALL BE FURNISHED A COMPLETED COPY OF THIS FORM.
NOTIFICATION OF SITE SELECTION FOR PHOTO INSPECTION
THIS IS TO DOCUMENT YOUR NOTIFICATION ON 05/28/21 REGARDING A CONVENIENT PHOTO INSPECTION SITE
LOCATION IN YOUR AREA FOR THE FOLLOWING VEHICLE(S). PLEASE NOTE THAT A PHOTO INSPECTION IS
REQUIRED FOR THE FOLLOWING VEHICLE(S). YOU MAY HAVE YOUR VEHICLE(S) INSPECTED AT A
CONVENIENT CARCO SITE.
# YEAR MAKE MODEL VIN
1 2010 FORD EXPLORER XLT 1FMEU7DE2AUA91349

YOU MAY REVIEW THE CARCO SITE LOCATIONS AT www.carcogroup.com, OR YOU CAN CALL 1-888-242-1200 FOR
CARCO SITES.

APPLICANT SIGNATURE X DATE __________________________

05/28/21 11:08 AM CDT
MERRI L ANDREANO

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APPLICANT NAME: MERRI L ANDREANO POLICY NUMBER: NY5620173
APPLICANT STATEMENT – READ BEFORE SIGNING

I represent that the statements and answers recorded on this application are true and complete to the best of my knowledge and
belief. I agree that any policy issued from this application shall be subject to cancellation if any of these answers are false,
incomplete, or given with the intent to deceive.
I state that there are no persons, age 16 or over, residing in my household and/or who are furnished any vehicle insured on this
policy on a regular basis other than the person(s) listed on this signed application. I understand that the Company relied on this
information by issuing my policy and may deny coverage and/or cancel this policy if I made any fraudulent omissions,
misrepresentations, concealment of facts, or incorrect statements as to any fact or condition that is material either to the hazard
assumed by the Company, or to the acceptance of the risk; and the Company would not have in good faith issued the policy, or
provided the coverage with respect to the hazard resulting in the loss, if the true facts had been known as required by this policy
application.
I understand and agree that I will notify the Company of any driver changes that occur during the policy period.
I certify that all vehicles listed on this policy with an indication of “Personal” in the “Vehicle Use” box are used solely for pleasure.
It is my duty to notify the Company if any of these vehicles may later be used for business. I understand acceptable and non-
acceptable business usage.
I affirm that if I make my initial payment by credit card, the coverage afforded under this policy is conditioned on payment to the
Company by the credit 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 cancelled.
I acknowledge that cancellations at my request will be cancelled short-rate, including non-payment of premium and/or fees on
direct bill policies.
I understand that a returned payment fee of $20.00 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 agree to pay a $7 phone payment fee for payments made over the phone.
If paying by installments, I agree to pay a $12 billing fee.
I agree to pay a $25 reinstatement fee for any policy that is reinstated due to late payments.
I agree to pay a $7 endorsement fee for changes to my policy made over the phone.
I understand that I am responsible for paying any applicable fees or charges described above, and that failure to pay any fees or
charges may result in policy cancellation, non-renewal or collection proceedings.
I warrant that no accident otherwise insurable under the policy requested has occurred on the date of this application. I agree the
Company may order consumer reports or personal or privileged information concerning credit, personal characteristics, driving
record, or loss history in connection with my application for a premium quotation or policy. It is not our policy to disclose this
information collected except to carry out our obligations under your policy, to enforce our rights under your policy or to respond to
a request from a court or governmental agency. At your request, we will provide the name and address of the consumer reporting
agency that furnished any of this information. At your request, we will provide you with more detailed information regarding our
collection, use, and disclosure of personal information and your rights to access and correct such information. I acknowledge that
damage incurred prior to the inception date of this policy will not be afforded coverage.
NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES – REGULATION 95
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any
person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires
with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law
enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which
is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor
vehicle or stated claim for each violation.

APPLICANT SIGNATURE X DATE ______________________

05/28/21 11:08 AM CDT
MERRI L ANDREANO
X THE GENERAL AUTO INS SVCS, INC
_________________________________________________________________________________________________________
05/28/21 11:08 AM CDT
SIGNATURE OF COMPANY APPROVED AGENT DATE

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