Envelope PDF

DocuSign Envelope ID: 28693686-9073-41B0-960F-223382C01777
AAA Insurance Agency

PO Box 31087
Tampa, FL 336330415
(800) 222-3854
Florida Application for Automobile Insurance

Policy Information
Effective Date Expiration Date Binder / Application #

05/30/2010 05/30/2011 ACF1068140
Prior Liability Carrier Policy # Exp Length of time insured

Auto Club South Ins. Co. GAP00020784 05/30/2010 Over 2 years coverage
Prior Limits: 100/300 or greater
Applicant Information
Applicant Name(s) (First, MI, Last) Home Phone Work Phone

GABRIEL TRAVERS (619) 884-0323
Mailing Address
1700 Jake St Unit 207 Orlando FL 32814-5908
Vehicle Information
VEH. NEW/ DATE
NO. YEAR MAKE MODEL VIN USED PURCHASED
1 2003 TOYOTA 4RUNNER SR5/SPORT EDITION JTEZU14R030006259
COST STATE ANNUAL VEHICLE AIR

ANTI-
NEW REG. MILEAGE USAGE HOW TITLED BAG ANTI-THEFT
LOCK
1 2003 TOYOTA FL 12000 Work/School Insured YES YES YES
ACS415 (09/05) Page 1

Auto Club South Insurance Company

Applicant Name(s) (First, MI, Last) Effective Date Expiration Date Binder / Application #
GABRIEL TRAVERS 05/30/2010 05/30/2011 ACF1068140
Coverage Information Premium Premium Premium Premium

VEH# 1
2003 TOYO
4RUNNER
SR5/SPORT
EDITION
BODILY PER PER
INJURY $250,000 PERSON $500,000 OCCURRENCE $540.00
PROPERTY PER
DAMAGE $100,000 OCCURRENCE $244.00
MEDICAL PER $104.00

PAYMENTS $5,000 PERSON
UNINSURED MOTORIST PER PER
$229.00
- NON-STACKED $250,000 PERSON $500,000 OCCURRENCE
PERSONAL INJURY PROTECTION $10,000 $342.00
OTHER THAN COLLISION
DEDUCTIBLE VEHICLE(S) #1 $100 $65.00
COLLISION
DEDUCTIBLE VEHICLE(S) #1 $250 $302.00
RENTAL PER PER

REIMBURSEMENT $30 DAY $900 OCCURRENCE $34.00
CUSTOMIZING
EQUIPMENT
AUDIO/
VISUAL
FHCF Emergency Assessment $19.00
TOTAL VEHICLE PREMIUMS $1,879.00
TOTAL POLICY PREMIUM $1,879.00
PAYMENT PLAN: Paid In Full

Down Payment of $1,879.00 is required as payment in full.
No Service Charge On Down Payment.
ACS415 (09/05) Page 2


Underwriting Questions Use Application Remarks for any explanations.
A) HOW MANY MONTHS OF THE YEAR DOES THE APPLICANT SPEND OUT OF FLORIDA? None
WHERE IS REMAINING TIME SPENT?
DOES CAR REMAIN IN FLORIDA? NO YES
B) HAVE ALL REGULAR AND INFREQUENT DRIVERS, IN THE HOUSEHOLD, BEEN

DISCLOSED ON THE APPLICATION? NO YES X
C) HAVE ALL REGULAR AND INFREQUENT OPERATORS, OF ALL VEHICLES, BEEN

DISCLOSED ON THE APPLICATION? NO YES X
D) HAVE ALL VEHICLES IN THE HOUSEHOLD BEEN DISCLOSED ON THE APPLICATION? NO YES X
E) HAVE ALL RESIDENTS, AGE 14 AND OVER, BEEN DISCLOSED ON THE APPLICATION? NO YES X
F) IS POLICY ADDRESS YOUR PERMANENT OR LEGAL RESIDENCE? NO YES X
G) OWN OR RENT? RENT
H) PREVIOUS ADDRESS, IF LESS THAN 2 YEARS AT PRESENT? 1699 CHATHAM PARKWAY #1710B, SAVANNAH, GA 31405
I) ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWED IN THE LAST 3 YEARS? NO X YES
J) ANY VEHICLES BEEN MODIFIED OR CUSTOMIZED? NO X YES
K) ANY VEHICLES USED FOR DELIVERY OR PICKUP OF GOODS OR PEOPLE? NO X YES
L) ANY VEHICLES PREVIOUSLY DECLARED A TOTAL LOSS? NO X YES
M) ANY DRIVER HAD LICENSE SUSPENDED OR REVOKED WITHIN THE PAST 5 YEARS? NO X YES
ARE YOU AN AAA MEMBER? NO YES X MEMBERSHIP # 4290146212196804 DATE JOINED: 05/05/1981
ACS415 (09/05) Page 3


Household Residents
MARITAL RELATION DRIVER

# NAME BIRTH DATE GENDER STATUS TO INSURED STATUS
1 GABRIEL TRAVERS 01/05/1985 M Single Insured Active
2 ROBERT KANTZ 08/12/1985 M Single Other Excluded
DATE DRIVER'S PRINCIPAL/OCCASIONAL

# NAME LICENSED LICENSE NUMBER STATE OPERATOR
1 GABRIEL TRAVERS 01/05/2001 T616284850050 Florida Principal; Veh 1
2 ROBERT KANTZ 08/12/2001 K532772852920 Florida Occasional; Veh
# DISCOUNT(S) OCCUPATION YEARS EMPLOYED EMPLOYER / ADDRESS

1 No Office Professional
2 No Office Professional
ANY DRIVERS AWAY AT SCHOOL? NO
IF PRESENT LICENSE HELD LESS THAN 3 YEARS, SHOW DRIVER NUMBER (FROM ABOVE) PREVIOUS DRIVER'S LICENSE
NUMBER AND STATE IF AVAILABLE:
# LICENSE # STATE # LICENSE # STATE # LICENSE # STATE
Driving Record
LIST ALL MOVING VIOLATIONS, ACCIDENTS (WHETHER AT FAULT OR NOT) OR PHYSICAL DAMAGE LOSSES
B/I INJURY
ACCIDENT OR DEATH AMOUNT
# NAME DATE DESCRIPTION (Y/N) (Y/N) PAID
ACS415 (09/05) Page 4


Application Remarks:
EXCLUDED ROOMATE PER INSURED REQUEST.
Remarks
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Company Use:
SL/ 17 IS/ 5/I
# TERR SYM SCF BISYM BISYMF PIPSYM PIPSYMF DCLASS

1 060 13 .00000 305 1.05000 520 1.20000 SM25
ACS415 (09/05) Page 5


Statement of Applicant
I REPRESENT THAT ALL THE ANSWERS TO ALL QUESTIONS IN THIS APPLICATION ARE TRUE AND CORRECT; AND I UNDERSTAND,
RECOGNIZE AND AGREE THAT SAID ANSWERS ARE GIVEN AND MADE FOR THE PURPOSE OF INDUCING THE COMPANY TO ISSUE ME
A POLICY FOR WHICH I HAVE APPLIED. IN THE EVENT THE POLICY IS ISSUED, COVERAGE MAY BE DECLARED VOID IF ANY OF SAID
ANSWERS ARE FALSE AND MATERIALLY AFFECT THE RISK WHICH THE COMPANY ASSUMES BY ISSUING THE POLICY.
I UNDERSTAND THAT PURSUANT TO FLORIDA STATUTES, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD,
OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR
MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
I UNDERSTAND THAT THE TOTAL PREMIUM SHOWN ON THIS APPLICATION IS BASED IN PART UPON THE ASSUMPTION THAT THE
INFORMATION I HAVE PROVIDED REGARDING MY DRIVING RECORD, THE DESIGNATION OF AND INFORMATION CONCERNING OTHER
OPERATORS OF THE INSURED VEHICLE AND THEIR DRIVING RECORDS, AND THE PRINCIPAL LOCATION OF THE INSURED VEHICLE, IS
ACCURATE AND COMPLETE.
I UNDERSTAND THAT AS PART OF ROUTINE UNDERWRITING PROCEDURES, THE COMPANY MAY ORDER CONSUMER REPORTS
(INCLUDING CONSUMER CREDIT REPORTS) OR PERSONAL PRIVILEGED INFORMATION CONCERNING CHARACTER, GENERAL
REPUTATION, PERSONAL CHARACTERISTICS, DRIVING RECORD, LOSS HISTORY AND MODE OF LIVING ABOUT MYSELF AND ALL
RESIDENTS AND INDIVIDUALS LISTED ON THIS APPLICATION. UPON WRITTEN REQUEST, I WILL BE PROVIDED THE NAME, ADDRESS,
AND PHONE NUMBER OF THE CONSUMER REPORTING AGENCY THAT FURNISHED ANY OF THIS INFORMATION.
AT LEAST 60 DAYS PRIOR TO THE EXPIRATION DATE, I MAY REQUEST A RE-ORDER OF THE CONSUMER REPORTS FOR
CONSIDERATION AT RENEWAL. INFORMATION CONTAINED IN THE CONSUMER REPORTS COULD CAUSE A PREMIUM CHANGE, NO
CHANGE OR NON-RENEWAL OF THE POLICY.
IF THE COMPANY DETERMINES THAT ANY INFORMATION IS INACCURATE OR INCOMPLETE, AND IF I AM NOTIFIED OF ANY ADDITIONAL
PREMIUM BASED ON ACCURATE AND COMPLETE INFORMATION, I UNDERSTAND THAT MY OPTIONS ARE: (A) TO PAY THE ADDITIONAL
PREMIUM DUE AS BILLED OR (B) WITHIN 10 DAYS OF NOTIFICATION CANCEL THE POLICY AND RECEIVE A REFUND OF ANY UNEARNED
PREMIUM.
DATE SIGNED APPLICANT'S SIGNATURE DATE SIGNED CO-APPLICANT'S SIGNATURE
I Represent That:
ALL REGULAR AND INFREQUENT DRIVERS IN THE HOUSEHOLD HAVE BEEN DISCLOSED TO THE COMPANY ON THIS APPLICATION.
ALL REGULAR AND INFREQUENT OPERATORS OF ALL VEHICLES HAVE BEEN DISCLOSED TO THE COMPANY ON THIS APPLICATION.
ALL PERSONS AGE 14 OR OVER, WHO LIVE IN THE HOUSEHOLD, HAVE BEEN DISCLOSED TO THE COMPANY ON THIS APPLICATION.
ALL VEHICLES IN THE HOUSEHOLD HAVE BEEN DISCLOSED TO THE COMPANY ON THIS APPLICATION.
DATE SIGNED APPLICANT'S SIGNATURE DATE SIGNED CO-APPLICANT'S SIGNATURE
AAA Insurance Agency SCH FL Steve K. Chaves

PO Box 31087 SCSR CODE AGENT
Tampa, FL 336330415
(800) 289-1325
AGENT LICENSE # AGENT'S SIGNATURE
ACS415 (09/05) Page 6

NAMED DRIVER EXCLUSION AGREEMENT
In consideration of the premium charged, it is agreed we will not provide coverage or

defend or pay for any claim arising out of an accident or loss which occurs while any
vehicle insured under this policy is driven with or without your permission by:
Required Excluded Driver Information:
Relationship To Named
Name DOB Insured
Robert Kantz 08/12/1985 Other
In accordance with the Motor Vehicle Laws of the State of Florida, this exclusion does
not apply to any losses covered under Personal Injury Protection Coverage or Property
Damage Liability.
The provisions of this agreement supersede and exclude from the policy any contrary
provision(s).
The undersigned, the named insured in this policy, hereby consents and agrees to this
amendment to the policy.
Named Insured's Signed Acceptance Date
Named Insured's Spouse (if necessary) Date
Named Insured (as shown on Declaration) Gabriel Travers
Attached to and forms part of policy number ACF1068140
Policy Effective Date May 30,2010
Issued by:
AUTO CLUB SOUTH INSURANCE COMPANY
Tampa, Florida
ACS120 (09/04)
PERSONAL INJURY PROTECTION (PIP) OPTIONS

PERSONAL INJURY PROTECTION COVERAGE: PERSONAL INJURY PROTECTION (PIP) HAS
BEEN OFFERED AND EXPLAINED TO ME. I AUTHORIZE THAT MY POLICY BE ISSUED AS
FOLLOWS:
The term "named insured" referred to below is defined in the policy as the person named in the
Declarations or that person's spouse, if a resident of the same household.
For personal injury protection insurance, the named insured may elect a deductible and to exclude coverage
for loss of gross income and loss of earning capacity ("lost wages"). These elections apply to the named
insured alone, or to the named insured and all dependent resident relatives. A premium reduction will
result from these elections. The named insured is hereby advised not to elect the lost wages exclusion if
the named insured or dependent resident relatives are employed, since lost wages will not be payable in the
event of an accident.
X Personal Injury Protection with NO DEDUCTIBLE
Personal Injury Protection with the DEDUCTIBLE checked below:

(Check one box)
Named Insured
and Dependent
Named Insured OR Family Members
$ 250
$ 500
$ 1,000
I elect to exclude Work Loss for:

The Named Insured and
Named Insured Dependent Family Members
The following coverages are available only to those insureds whose prior policy provided this coverage.
I elect to add the following amount of Personal Injury Protection

coverage. Extended PIP must also be elected.
$10,000
$25,000
$40,000
$90,000
I elect to extend Personal Injury Protection coverage.
GABRIEL TRAVERS ACF1068140

Name (please print) Policy Number
Signature Date
ACS124 (10/03)
FLORIDA UNINSURED MOTORIST COVERAGE

ELECTION / REJECTION FORM
YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE
WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING
UNINSURED MOTORIST LIMITS LESS THAN YOUR BODILY INJURY LIABILITY
LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY.
Uninsured Motorist coverage provides for payment of certain benefits for damages caused by owners or operators of
uninsured motor vehicles because of bodily injury or death resulting therefrom. Such benefits may include payments
for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the
policy. For the purpose of this coverage, an uninsured motor vehicle may include a motor vehicle as to which the bodily
injury limits are less than your damages.
Florida law requires that automobile liability policies include Uninsured Motorist coverage at limits equal to the Bodily
Injury Liability limits in your policy unless you select a lower limit offered by the company, or reject Uninsured Motorist
entirely.
Please indicate whether you desire to entirely reject Uninsured Motorist coverage, or whether you desire this coverage
at limits lower than the Bodily Injury Liability limits of your policy:
a. I hereby reject Uninsured Motorist coverage.
b. I hereby select Uninsured Motorist limits of $___________________which are

lower than my Bodily Injury Liability limits.
ELECTION OF NON-STACKED COVERAGE

(Do not complete if you have rejected Uninsured Motorist)
You have the option to purchase, at a reduced rate, non-stacked (limited) type of Uninsured Motorist coverage. Under
this form if injury occurs in a vehicle owned or leased by you or any family member who resides with you, this policy
will apply only to the extent of coverage (if any) which applies to that vehicle in this policy. If an injury occurs while
occupying someone else's vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of
Uninsured Motorist coverage available on any one vehicle for which you are a named insured, insured family member, or
insured resident of the named insured's household. This policy will not apply if you select the coverage available under
any other policy issued to you or the policy of any other family member who resides with you.
If you do not elect to purchase the non-stacked form, your policy limit(s) for each motor vehicle are added together
(stacked) for all covered injuries. Thus, your policy limits would automatically change during the policy term if
you increase or decrease the number of autos covered under the policy.
X I hereby elect the non-stacked form of Uninsured Motorist coverage.
I understand and agree that selection of any of the above options applies to my liability insurance policy and future
renewals or replacements of such policy which are issued at the same Bodily Injury Liability limits. If I decide to
select another option at some future time, I must let the Company or my agent know in writing.
GABRIEL TRAVERS ACF1068140

Name (please print) Policy Number
Signature Date
Signature Date
ACS112 (5/98)
AUTO CLUB SOUTH INSURANCE COMPANY
***FAIR CREDIT REPORTING ACT***

NOTICE REGARDING YOUR POLICY PREMIUM
In compliance with the Fair Credit Reporting Act we are informing you that your policy
rate is based in part on information contained in a consumer credit report obtained from a
consumer credit reporting agency. The amount that you are charged for your policy is
based on rates we have on file with the Department of Insurance in your state. The
consumer credit reporting agency will not be able to tell you how your rate is
determined, but you may wish to review the information that they supply us. You may
obtain a free copy of the consumer credit report from ChoicePoint, the consumer credit
reporting agency, if you contact them no later than 60 days after receipt of this
notification. You have the right to dispute, with the consumer credit reporting agency,
the accuracy or completeness of any information contained in the consumer credit report.
ChoicePoint can be contacted by telephone or mail at:
ChoicePoint National Consumer Service Center

P. O. Box 105108
Atlanta, GA 30348-5108
Telephone: 1-800-456-6004 (Monday through Friday 8:00 a.m. - 7:00 p.m.)
www.consumerdisclosure.com
Please be advised that you also have the right to request that we re-evaluate the
information we obtain from this consumer credit reporting agency to determine whether
you now qualify for a lower premium. You may make this request by contacting your
local AAA branch office or the Customer Response Unit at 1-800-289-1325.
INSURED COPY
12/08/2003 ACF1068140
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response

Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer reporting
agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records). Here is a summary of your major
rights under the FCRA. For more information, including information about additional rights, go to
www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
* You must be told if information in your file has been used against you. Anyone who uses a
credit report or another type of consumer report to deny your application for credit, insurance,
or employment – or to take another adverse action against you – must tell you, and must give
you the name, address, and phone number of the agency that provided the information.
* You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file disclosure”). You
will be required to provide proper identification, which may include your Social Security
number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
* a person has taken adverse action against you because of information in your credit
report;
* you are the victim of identify theft and place a fraud alert in your file;
* your file contains inaccurate information as a result of fraud;
* you are on public assistance;
* you are unemployed but expect to apply for employment within 60 days.
In addition, by September 2005 all consumers will be entitled to one free disclosure every 12
months upon request from each nationwide credit bureau and from nationwide specialty
consumer reporting agencies. See www.ftc.gov/credit for additional information.
* You have the right to ask for a credit score. Credit scores are numerical summaries of your
credit-worthiness based on information from credit bureaus. You may request a credit score
from consumer reporting agencies that create scores or distribute scores used in residential
real property loans, but you will have to pay for it. In some mortgage transactions, you will
receive credit score information for free from the mortgage lender.
* You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer reporting
agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit
for an explanation of dispute procedures.
* Consumer reporting agencies must correct or delete inaccurate, incomplete, or
unverifiable information. Inaccurate, incomplete or unverifiable information must be
removed or corrected, usually within 30 days. However, a consumer reporting agency may
continue to report information it has verified as accurate.
UCD-3 Effective: 12/01/2005 A Summary of Your Rights Under the Fair Credit Reporting Act
* Consumer reporting agencies may not report outdated negative information. In most
cases, a consumer reporting agency may not report negative information that is more than seven
years old, or bankruptcies that are more than 10 years old.
* Access to your file is limited. A consumer reporting agency may provide information about
you only to people with a valid need -- usually to consider an application with a creditor,
insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for
access.
* You must give your consent for reports to be provided to employers. A consumer
reporting agency may not give out information about you to your employer, or a potential
employer, without your written consent given to the employer. Written consent generally is not
required in the trucking industry. For more information, go to www.ftc.gov/credit
* You may limit "prescreened" offers of credit and insurance you get based on information
in your credit report. Unsolicited "prescreened" offers for credit and insurance must include
a toll-free phone number you can call if you choose to remove your name and address from the
lists these offers are based on. You may opt-out with the nationwide credit bureaus at
1-888-5-OPTOUT (1-888-567-8688).
* You may seek damages from violators. If a consumer reporting agency, or, in some cases, a
user of consumer reports or a furnisher of information to a consumer reporting agency violates
the FCRA, you may be able to sue in state or federal court.
* Identity theft victims and active duty military personnel have additional rights. For more
information, visit www.ftc.gov/credit
States may enforce the FCRA, and many states have their own consumer reporting laws. In
some cases, you may have more rights under state law. For more information, contact your state
or local consumer protection agency or your state Attorney General. Federal enforcers are:
TYPE OF BUSINESS: CONTACT:

Consumer reporting agencies, creditors and others not listed below Federal Trade Commission: Consumer Response Center - FCRA
Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks (word Office of the Comptroller of the Currency
"National" or initials "N.A." appear in or after bank's name) Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national banks, and Federal Reserve Board
federal branches/agencies of foreign banks) Division of Consumer & Community Affairs
Washington, DC 20551 202-452-3693
Savings associations and federally chartered savings banks (word Office of Thrift Supervision
"Federal" or initials "F.S.B." appear in federal institution's name) Consumer Complaints
Washington, DC 20552 800-842-6929
Federal credit unions (words "Federal Credit Union" appear in National Credit Union Administration
institution's name) 1775 Duke Street
Alexandria, VA 22314 703-519-4600
State-chartered banks that are not members of the Federal Reserve Federal Deposit Insurance Corporation
System Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil Department of Transportation , Office of Financial Management
Aeronautics Board or Interstate Commerce Commission Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250 202-720-7051
UCD-3 Effective: 12/01/2005 A Summary of Your Rights Under the Fair Credit Reporting Act
 
ACKNOWLEDGEMENT OF REQUIREMENT FOR PREINSURANCE INSPECTION

(This is not a safety inspection)
IMMEDIATE ACTION REQUIRED TO AVOID LOSS OF INSURANCE COVERAGE
Policy / Quote #: ___________________________________

ACF1068140 Effective date of
Insured Name: ___________________________________
GABRIEL TRAVERS coverage: ________________________
May 30, 2010
Address: __________________________________________
1700 JAKE ST UNIT 207 (Date)
__________________________________________
ORLANDO, FL 32814 Inspection must be
completed by: _____________________
Jun 6, 2010
(Date)
Please list all vehicles on policy

Year Make Model VIN Inspection Inspection Exemption
Reqd Reason
1. _______
2003 ______________
TOYOTA _______________
4RUNNER jtezu14r030006259
__________________ over 10 miles from ismc office
Y__ N__ ______________________
2. _______ ______________ _______________ __________________ Y__ N__ ______________________
3. _______ ______________ _______________ __________________ Y__ N__ ______________________
4. _______ ______________ _______________ __________________ Y__ N__ ______________________
By my signature below, I acknowledge that I have been informed that my vehicle(s) noted above as requiring an
inspection, which is/are being insured for Comprehensive (Other Than Collision) and/or Collision coverage,
must be inspected by a representative of the insurer. This inspection must be completed within thirty (30) days
(not including legal holidays) after the effective date of coverage, and in no event later than the date shown
above to avoid a suspension in coverage.
I understand the failure to submit to the required inspection(s) may result in the suspension (losses will not be
covered) of Comprehensive (Other Than Collision) and Collision coverages as of 12:01AM of the date
following the date by which the inspection must be completed, as shown above.
I understand that if coverage is suspended it will be restored only after the inspection has been completed and
the adjusted premium due for such coverage(s) has been paid.
________________________________________________ _________________
Insured Signature Date
________________________________________________ _________________
Producer / Insurance Company Representative Signature Date
Name, Address & Telephone Number AAA INSURANCE AGENCY

____________________________________________
of Producer / Representative Completing ____________________________________________
1211 FIRST AVE N ST. PETERSBURG, FL 33705
this Form: ____________________________________________
STEVEN CHAVES 1.800.222.3854X6228
INSURED MUST RECEIVE A COMPLETED COPY OF THIS FORM

Florida/Georgia/Tennessee Waivers & Disclaimers - Vehicle
Your insurance representative will check all that apply to your new policy. Please read and initial each checked
statement indicating your understanding and acceptance.
My signature below acknowledge(s) that I am aware that the liability limits selected (Limits: / / )
are the minimal amounts available. My insurance representative has explained that I have minimal protection for
damages/injuries to others for which I may be legally liable. I understand the potential consequences.
My signature below acknowledge(s) that I am aware that the liability limits selected (Limits:
250000/500000/250000) are less than the limits (250000/500000/100000) afforded under my previous automobile
policy. My insurance representative has explained that I now have less protection for damages/injuries to others
for which I may be legally liable. I understand the potential consequences.
I have elected NOT to purchase Comprehensive/Other Than Collision coverage (for example: fire, theft, wind,
hail, vandalism, glass breakage, flood) on my (yr) (make) (model) ; (yr) (make)
(model) ; (yr) (make) (model) .
I have elected NOT to purchase Collision coverage (physical damage due to an accident, hit & run) on my
(yr) (make) (model) ; (yr) (make) (model) ; (yr) (make)
(model) .
My insurance representative has provided me with a quote for Rental Reimbursement Coverage and I have elected
NOT to purchase Rental Reimbursement coverage on my (yr) (make) (model) ;
(yr) (make) (model) ; (yr) (make) (model) .
I have elected NOT to purchase GAP Coverage on my recently acquired vehicle. I understand that in the event of
a total loss to a covered auto, this coverage pays the difference between the actual cash value (ACV) and the
unpaid balance of the lease or loan on a new vehicle. Limitations apply.
I understand Repair or Replacement Coverage is available for new vehicles purchased from a new car dealer. In
the event of a total loss, this coverage will pay for the cost of a new vehicle of the same make/model. Limitations
apply. I have elected NOT to purchase this coverage.
I have elected to receive policy documents electronically instead of by conventional mail. I will maintain a valid
email address and advise AAA and /or the Company of any change.
I understand the policy has been rated based on the statements and information presented in this application. I
understand it is my responsibility to notify AAA Insurance Agency of any change in risk and may result in
additional premium or eligibility.
I understand my premium has been reduced due to a paid in full discount. Should I elect to change payment plans
in the future, I understand the discount will be removed and service fees may be incurred.
I understand special equipment must be listed on the application or endorsed on the policy and an additional
premium paid for coverage to apply. Equipment/features are installed by the manufacturer, but are not part of the
basic option package (for example: CD players, high value stereos, pick-up bed liners, camper tops, awnings,
wheel chair lifts, permanently installed car telephones, murals/paintings.)
Other:
OTHER EXCLUSIONS AND LIMITATIONS MAY APPLY – READ YOUR POLICY CAREFULLY
Name GABRIEL TRAVERS Signature:
Policy Number: ACF1068140 Effective Date: 05/30/2010
Today’s Date: 05/25/2010 Agent Name: STEVEN CHAVES
Rev 3/25/10
 
PAYMENT AUTHORIZATION
Recurring Payments
I confirm premium payments for my insurance policy will be taken directly

from the bank account provided on a monthly basis (EFT).
I confirm premium payments for my insurance policy will be charged directly

to the credit card provided on a monthly basis (RCC).
I understand that this is a recurring authorization and will remain in effect for
future policy terms. I can change payment information by providing the Company a
14 day written notice.
One Time Payments
I confirm a one time payment of $ 1,879 will be charged to the credit card
provided.
I confirm a one time payment of $ will be taken from the bank

account provided.
GABRIEL TRAVERS
Insured Name: ___________________________ ACF1068140
Policy #:______________
Signature:_______________________________ Date:_________________
Revised 2/15/10

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DocuSign Envelope ID: 28693686-9073-41B0-960F-223382C01777

AAA Insurance Agency

Florida Application for Automobile Insurance

Effective Date Expiration Date Binder / Application #

Prior Liability Carrier Policy # Exp Length of time insured

Prior Limits: 100/300 or greater

Applicant Name(s) (First, MI, Last) Home Phone Work Phone

1 2003 TOYOTA 4RUNNER SR5/SPORT EDITION JTEZU14R030006259

COST STATE ANNUAL VEHICLE AIR

1 2003 TOYOTA FL 12000 Work/School Insured YES YES YES

ACS415 (09/05) Page 1

Auto Club South Insurance Company

Coverage Information Premium Premium Premium Premium

MEDICAL PER $104.00

RENTAL PER PER

TOTAL VEHICLE PREMIUMS $1,879.00

TOTAL POLICY PREMIUM $1,879.00

PAYMENT PLAN: Paid In Full

ACS415 (09/05) Page 2

Auto Club South Insurance Company

Underwriting Questions Use Application Remarks for any explanations.

WHERE IS REMAINING TIME SPENT?

DOES CAR REMAIN IN FLORIDA? NO YES

B) HAVE ALL REGULAR AND INFREQUENT DRIVERS, IN THE HOUSEHOLD, BEEN

C) HAVE ALL REGULAR AND INFREQUENT OPERATORS, OF ALL VEHICLES, BEEN

F) IS POLICY ADDRESS YOUR PERMANENT OR LEGAL RESIDENCE? NO YES X

G) OWN OR RENT? RENT

I) ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWED IN THE LAST 3 YEARS? NO X YES

J) ANY VEHICLES BEEN MODIFIED OR CUSTOMIZED? NO X YES

K) ANY VEHICLES USED FOR DELIVERY OR PICKUP OF GOODS OR PEOPLE? NO X YES

L) ANY VEHICLES PREVIOUSLY DECLARED A TOTAL LOSS? NO X YES

ACS415 (09/05) Page 3

Auto Club South Insurance Company

MARITAL RELATION DRIVER

DATE DRIVER'S PRINCIPAL/OCCASIONAL

# DISCOUNT(S) OCCUPATION YEARS EMPLOYED EMPLOYER / ADDRESS

ANY DRIVERS AWAY AT SCHOOL? NO

# LICENSE # STATE # LICENSE # STATE # LICENSE # STATE

ACS415 (09/05) Page 4

Auto Club South Insurance Company

SL/ 17 IS/ 5/I

# TERR SYM SCF BISYM BISYMF PIPSYM PIPSYMF DCLASS

ACS415 (09/05) Page 5

Auto Club South Insurance Company

DATE SIGNED APPLICANT'S SIGNATURE DATE SIGNED CO-APPLICANT'S SIGNATURE

DATE SIGNED APPLICANT'S SIGNATURE DATE SIGNED CO-APPLICANT'S SIGNATURE

AAA Insurance Agency SCH FL Steve K. Chaves

ACS415 (09/05) Page 6

NAMED DRIVER EXCLUSION AGREEMENT

In consideration of the premium charged, it is agreed we will not provide coverage or

Required Excluded Driver Information:

Named Insured's Signed Acceptance Date

Named Insured's Spouse (if necessary) Date

Named Insured (as shown on Declaration) Gabriel Travers

Attached to and forms part of policy number ACF1068140

Policy Effective Date May 30,2010

PERSONAL INJURY PROTECTION (PIP) OPTIONS

X Personal Injury Protection with NO DEDUCTIBLE

FAIR CREDIT REPORTING ACT