WIXLIB

NJAPPLICATION FOR ANTIQUE & CLASSIC AUTO INSURANCENJJ.C. Taylor Antique Automobile Agency, Inc.320 South 69th Street, Upper Darby, PA 19082Phone: 1-800-345-8290 – Toll FreeFax: 610-853-0114www.JCTaylor.comApplicant Date of Birth OccupationStreet Phone Number E-mailCity County State ZipList all Licensed Drivers in household:DRIVER'S NAMESTATE & DRIVER'SLICENSE NUMBERDATE OF BIRTHNUMBER OF YRS.LICENSEDYEAR & MAKE OF VEHICLE DRIVENFOR DAILY USE*Co.1.)2.)3.)Attach a separate sheet for additional drivers.The following coverages are available. Indicate your selections by placing an “X” in the proper box.SINGLE LIMIT LIABILITY (VT Verbal Tort Threshold)* If company vehicle, check ( )All Rates are Annual Rates.TOTALLiability(VT) – 100,000 Single Limit Bodily Injury and Property Damage - 1st Vehicle 19.50, 2nd 13.00, 3rd 6.50, Addl Veh. - No Charge Liability(VT) – 300,000 Single Limit Bodily Injury and Property Damage - 1st Vehicle 26.00, 2nd 18.20, 3rd 10.40 Addl Veh. - No ChargeLiability – Other limits available. Please contact customer service for other limits and rates.Note: If you choose No Tort Threshold, double the above rates.*Personal Injury Protection (standard) – 250,000 Combined Single Limit - 1st Vehicle 5.20, 2nd 3.90, 3rd 2.60, Addl Veh. - No Charge*Additional Personal Injury Protection – Please contact customer service for limits and rates*Uninsured/Underinsured Motorist Coverage – Please see the table on back for limits and rates and enter the proper premium.1st Vehicle2nd Vehicle3rd Vehicle Addl. Veh. – No Charge.*Selection/Rejection form may be required - see attached.Physical Damage – Other than Collision (Comprehensive) Coverage – Annual Rates - 0.35/hundred for Vehicles 25 years or older– Annual Rates - 0.70/hundred for Vehicles less than 25 years oldPhysical Damage – Collision CoverageTowing & Roadside Assistance – 12.00 per Policy (Note: Only available with Collision Coverage)– Annual Rates - 0.35/hundred for Vehicles 25 years or older– Annual Rates - 0.70/hundred for Vehicles less than 25 years oldNote: Collision Coverage is only available with Other than Collision (Comprehensive) CoverageTotal Annual Premium Requested effective date of coverage Minimum Policy Premium is 75.00ANTIQUE VEHICLES TO BE INSURED**We require: 1) Recent color photo of each vehicle listed, 2) A copy of your primary Auto Policy & 3) Payment in full at the time of submission of this applicationIS THIS VEHICLE STATE OFBODY TYPEVEHICLE IDENTIFICATION,YEARMAKEVALUEREGISTERED?REGISSERIES OR MODELSERIAL OR MOTOR NUMBER(circle one)TRATION1)YesNo2)YesNo3)YesNo4)YesNoYesNo5)Use separate sheet for additional vehicles to be insured.** These vehicle(s) will be used mainly in exhibitions,club activities, parades and other functions of publicinterest and will not be used primarily for thetransportation of passengers or goods.Important! See other side foradditional questions and required signature.CSLNJAA0612Broker / Producer Information (if applicable)Producer NameAddressCity State ZipPhone FaxE-mail I.D.#PRODUCER CANNOT BIND COVERAGE. NO COVERAGE IS PROVIDEDUNTIL J.C. TAYLOR OR THE INSURER BINDS COVERAGE.

NJJ.C. Taylor Antique Automobile Agency, Inc.320 South 69th Street Upper Darby, PA 19082 1-800-345-8290 Fax 610-853-0114 www.JCTaylor.comNJTo properly expedite the handling of your application, please answer the following questions. Explain in detail for the necessary questions.1. Have you or any driver in your household had any auto losses or moving violations in the past 3 years? If Yes, explain.YesNo2. Will you be using your antique/classic vehicle as a means of daily transportation, errands, or back-up?YesNo3. Do you belong to an automobile club? If yes, which club?YesNoInclude: Date-Cause-Payment.4. Has (will) the body, engine, or drive train of the antique/classic vehicle been(be) changed?If yes, explainYesNo5. Has the manufacturer's horsepower for your vehicle been changed? If yes, explainYesNo6. Is any vehicle currently under restoration? If yes, a.) What is the expected date of completion?YesNoYesNob.) If in shop, list name and address7. Are all antique/classic vehicle(s) garaged?8. Construction of garage: Cinder Block Brick/Stone Wood Frame Other (explain)Location(s) of garage(s) a.) Same as mailing address? Yes NoIf No, list full garage address9. What is the annual mileage? (a) Club functions miles (b) Other purpose miles ExplainNew Jersey Fraud Warning:ANY PERSON WHO INCLUDES FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCEPOLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.1. In connection with this application for insurance I agree that the insurer may secure and review consumer reports, including motor vehicle records for personslisted in the application or subsequently added to the policy. I agree to allow the insurer to share my name, address, date of birth and social security number withthird party consumer reporting and insurance support organizations in order to obtain consumer reports. I further agree that the insurer may secure and reviewnew consumer reports in evaluating this policy, or for my request for a change in policy benefits, or for a replacement policy as permitted by law. I or myauthorized representative may request a copy of this authorization from my insurance representative.2. I declare that the information contained in this application is true to the best of my knowledge and belief. I understand that the insurer will rely on thisinformation in determining my eligibility and premium.3. I declare that the selections indicated in this application accurately reflect the limits, coverages and deductibles I chose.4. I understand my producer is submitting this application to an appointed agency of an insurer, and that my producer does not have binding authority with theinsurer. I understand I will not have coverage until I am informed by the appointed agency or the insurer that coverage is bound or issued.5. I agree that the insurer and its affiliates may use any telephone number, including any cell phone number, I provide now or in the future to contact me by way oflive calls or by use of any automatic dialing system or artificial or prerecorded voice.My vehicle(s) will be used mainly in exhibitions, club activities, parades and other functions of public interest and will not be used primarily for thetransportation of passengers or goods. There is no coverage until specific notification is made by J.C. Taylor.SIGNATURE OF APPLICANT(S)DATERates for Uninsured Motorist Coverage (Includes Underinsured Motorist & UMPD)1 Veh.2nd Veh.3rd Veh. 35,000 7.80 7.80 7.80 100,000 13.00 13.00 300,000 15.60 15.60Verbal Tort Thresholdst1st Veh.2nd Veh.3rd Veh. 35,000 11.70 11.70 11.70 13.00 100,000 16.90 16.90 16.90 15.60 300,000 19.50 19.50 19.50No Tort ThresholdNo Charge for Additional Vehicles. A 500 deductible applies to the Property Damage Uninsured Motorist Coverage.Higher limits up to 500,000/ 1,000,000 available upon request and with further underwriting review and copy of daily car policy. Please contact customer service for rates.APPOINTED AGENCYJ.C. TaylorAPPOINTED AGENCY CODE37-6790-999Underwritten by Foremost Insurance Company Grand Rapids, MichiganTo effect insurance, we require payment of entire premium, completed forms, photos, compliancewith state regulations and our acceptance of risk. There is no coverage until the producer or applicant is notified by J.C. Taylor.CSLNJAA0612Check List ( )() Signed, fully completed application() Check for full premium (Payable to J.C. Taylor AAA)() Signed state Selection/Rejection forms (if applicable)() Copy of primary auto policy declarations page() Recent, color photo of each vehicle. Photos may be e-mailed to service@jctaylor.com Date photos E-mailed:() Appraisal required when insured value falls outside of standard hobby valuation guides

Notice Of Information Practices Required By State nfiovtrahmcyatatweNotionimaycthe"e. ns")l coltrheatcleearictvee,, yeh. olOurders.information practices, as described in this notice, extend to applicants, policyholders and nomfroatmrmiaoattnioiweonn orneemayd fronemedyotuo comesverify infrfoomrmyatoiuonwhenyou havyoueapplgiveynfusor.inInsuthraosnce.e inSometstancesim,ewes, howevmay coentr, awect mayyou,yInouraddisptousion,eweor ewimayl makalesoeveobtry aefinforitntfoorcomplmatioyn wifrtohmyourconsrequesumert. reporting agencies and other sources for purposes other rinemplg rpoteporoeyntmtiinentagl fagencyrduraud,ingororthseeinrvspriucoriancesnceg ysoinsurugpporaccount.t organiiForm.zaPletixeoaanmplsmaye enot, webee:ofaclarAsetarienqeuid rbyedthbyat orthgeaniFaizartiCroneanddit Redipscorlotisnegd Actto ot, hweer peraresonotnsifwhoyingusyeouthesthate rewepormayts withinoutvesytiogurateautyohurorizcahtarion.acter, generalrnateputuraetandion, spercopesonalof anycharsauctcheriinsvtiecsstigandatiomoden requesoftelidvinwig,l whibe fcuhevrnisehredaretoapplyou,icuponable.yAddiour wrtioitnalen irnefquesormatt.ion regarding theTypTheto nCocolsulrlaeencectcteeddfuisncustioednst.o help us decide if you qualify for the insurance for which you have applied ofurmatvpoleiohin,icclipree(siso)covr, agesacceriidn, drgentivyseorurands, ,ti,nweprg itoomayrthareredrobtsitvsaeorrinsconvIn coinnectctionsio, nclawiimthsthihestunderory, andwritprinegviand/ous ionrsuserarvnceicinexg ofperpolience.icies covering your real and personal property, we may rmfoatrmioatn,ioclnariemlastihingstotorycons, ege,nceheat. ing, other physical characteristics eiaoinmIswen,fandocolrmalfeotctirootnabouthWeer sncetatefuandnctifoensder, ainlcllauw.dinForg underexamplwrieti,nweg andmaysedirvsicclionsgeytohurisinforAmgentatiosn,, brasokerpersmorit esdalbyes rlaew,prewisethntoutativyeosur prior authorization, to:APedjrsuosnstersor, approrganiaiszearsti,oinnsvewhostigatneoresd, andthe atintfoorrnmeyatsion to perform a busines , profes ional or insurance function for us,sAunotchhaser businsuinreasncees cthoatmpanyhelp usorwiinthsudatrancea prosuceppors intgororganimarzkaettioinn,g to detect or prevent criminal activity or fraud stittruatnsion:action, or to perform an insurance transaction12)) ttoo vinefroifryminysouuraofncaemedicovecralagecondior beneftion ofitswhich you may not be aware34)) ttoo conducdetermitnane whetaudihter services were reasonable and necessary 1 of 2 - 73 23 02/12