IS THE FOLLOWING DESCRIBED VEHICLE RATED BY THE TLC TO BE "WHEEL CHAIR ACCESSIBLE"?

IS THE VEHICLE LISTED BELOW A "HYBRID VEHICLE"?

IF MARRIED PLEASE ENTER THE SPOUCE'S NYC LICENSE NUMBER

BI $100,000 / $300.000PD $10,000PIP $50,000APIP $150,000UM $25,000 / $50,000SUM $25,000 / $50,000

Drivers Information

Next of KIN (other than spouse) to be contacted in case of emergency

FOR THE APPLICANT, LIST THE NAME OF THE PREVIOUS CARRIER AND LOSS EXPERIENCE FOR THE PAST 36 MONTHS

I understand that the coverage is provided for a single shift auto.I am the owner/exclusive driver vehicle of the policy. I further understand that in the event of an accident involving an unnamed driver or any changes in the conditions under which this policy was written the insurer reserves the rights to reclassify my policy or issue a notice of cancellation for misrepresentation.

IMPORTANT: 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 vehicle 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's Signature

Drivers's Signature

Producer's Signature

AN ANNUAL SERVICE FEE OF $20.00 WILL BE CHARGED PER INSTALLMENT

Underwriter's Signature