Insurance Application Policy Number: 11407202227

Dairyland County Mutual Insurance Effective Date: 08/09/2021

Company Of Texas 03:48 PM Central Time per Stevens Point, WI

My.DairylandInsurance.com

Named Insured(s)
BOWER, ROBERT B ALC Insure Inc
417 HOLLY LN Nadia Iqbal
VICTORIA TX 77905 1803 N Navarro Street
Phone: 361-550-9572 Victoria TX 77901
Email: rememberbubba69@gmail.com Phone: 361-578-7160

Premium, Coverage and Vehicle Information Type Powersports Policy Term 12 Month
Vehicle Number: 1

Year: 1995 Make: SUZUKI Model: GSX-R1100W VIN/Serial #: JS1GU75A4S2100598

Vehicle Type: Motorcycle Vehicle Location: 77905 CC's: 1100
Rated Driver: 1 Value: Existing Damage: N Inspection: N
Vehicle Capacity: N/A Licensed for Road Use: Y
Vehicle Level Coverages Limits Deductible Premium
Bodily Injury Liability $30,000 Each Person/$60,000 Each accident $292.88
Guest Passenger Liability Included in Bodily Injury Liability Included
Property Damage Liability $25,000 Each accident $136.40
Uninsured & Underinsured Motorist Bodily Injury Rejected
Uninsured & Underinsured Motorist Property Not Applicable Rejected
Damage
Personal Injury Protection Rejected
Medical Payments Not Selected
Comprehensive Not Selected
Collision Not Selected
Optional Equipment Not Selected
Diminishing Deductible™ Not Selected
Roadside Assistance Not Selected
Rental Reimbursement Not Selected
Physical Damage Plus Not Selected
Trip Interruption Not Selected
Special Processions Not Selected
Mexico Limited Coverage Not Selected
Replacement Cost Not Selected
Vehicle Premium $429.28

Policy Level Coverages Limits Deductible Premium

Transport Trailer Physical Damage Not Selected

Premium Summary

Premium Subtotal $429.28

Motor Vehicle Crime Prevention Authority Fee $4.00
Total Policy Premium $433.28
Total Amount Submitted $111.32
Pay Plan 5 Installments
Automatic Payments N

TXM1101-0121 (Policy # 11407202227) Page 1 of 3

Fee Information
The following fees may be charged during the life of the policy. These fees may change.
Late Fee Returned Billing Fee Automatic
Payment Fee Payments Billing
Fee

$5.00 $25.00 $6.00 $2.00

Discount Information
Driver Level
BOWER, ROBERT B 07/07/1988 Motorcycle Endorsement

Surcharge Information: None

Driver Information
Marital License
Drv # Name Date of Birth Gender Status State License Number Financial Responsibility
1 BOWER, ROBERT B 07/07/1988 M S TX 25368229

Non-Driver Information: None

Accident and Violation Information: None

Lienholder/Additional Insured/Additional Interest Information: None

TXM1101-0121 (Policy # 11407202227) Page 2 of 3

Named Insured Confirmation
I understand and agree this application is a part of the policy.
I understand and agree this policy does not take effect until the effective date and time listed on this application.
I understand and agree if a payment made by me or on my behalf to initiate a policy is not honored by the financial
institution, it will not be considered a valid payment and coverage may not be afforded under this policy.
I understand and agree any unpaid balance owed, including any fees, at the time of cancellation, non-renewal or
expiration is a debt the Company may attempt to collect.
I understand and agree the Company may obtain facts from third parties such as consumer reporting agencies or policy
verification services that provide driving and claims histories on all drivers rated on this policy. I understand and agree
new or updated consumer information may be used to calculate my renewal premium. I may access this information
directly from the third party and correct it if it is inaccurate.
I understand and agree, as permitted by Insurance Code Chapter 705, Subchapter A, this policy may be rescinded
and/or coverage denied if this application contains any misrepresentations shown at trial to be material to the risk or
contributed to the contingency or event on which the policy became due and payable. I understand and agree I must
disclose all persons who are regular operators of any vehicle to be insured, regardless of where they reside.
I understand and agree the Company may use a credit based insurance score determined by information contained in
my credit history. I understand and agree new or updated credit information may be used to calculate my renewal
premium. I may access this information directly from the third party and correct it if it is inaccurate.
I understand and agree it is my responsibility to promptly report any change of vehicle location to the Company and I
declare each vehicle listed in this application is garaged more than 50% of the time at the vehicle location listed.

I hereby appoint the president of Dairyland County Mutual Insurance Company Of Texas, with full power of substitution,
to be my lawful attorney in fact. In my absence he is hereby authorized and empowered to vote for me at any
membership meetings during the term of this policy and any renewal or replacement policy. This proxy will remain valid
for eleven months, unless I give written notice otherwise.
I ACKNOWLEDGE AND AGREE THAT BY CLICKING MY NAME ON THE DESIGNATED LINE(S) INDICATING “CLICK
HERE TO SIGN”, I AM ELECTRONICALLY SIGNING THIS APPLICATION, WHICH WILL HAVE THE SAME LEGAL
EFFECT AS THE EXECUTION OF THIS DOCUMENT BY A WRITTEN SIGNATURE AND SHALL BE VALID EVIDENCE OF
MY INTENT AND AGREEMENT TO BE BOUND BY ITS TERMS.

I hereby apply to the company for a policy of insurance. The above facts are true and complete. I understand this policy
is to be issued in reliance upon these facts being true.
8/9/2021, 3:49 PM LOCAL TIME AM
*
robert bower
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PM ({{Sig_es_:signer1:signature:dimension(width=50mm, height=8mm)}})

Date Signed Time Signed Named Insured's Signature

TXM1101-0121 (Policy # 11407202227) Page 3 of 3

Dairyland County Mutual Insurance Company Of Texas

My.DairylandInsurance.com

TEXAS PERSONAL INJURY PROTECTION COVERAGE REJECTION

AND LIMITED POWER OF ATTORNEY
I understand and hereby reject Personal Injury Protection Coverage as provided in Texas Insurance Code § 1952.
Further, I appoint Dairyland County Mutual Insurance Company Of Texas to be lawful Attorney-in-fact to continue this
rejection of Personal Injury Protection Coverage on all subsequent renewals or rewrites of this policy, unless and not
until I request this coverage in writing.
I ACKNOWLEDGE AND AGREE THAT BY CLICKING MY NAME ON THE DESIGNATED LINE(S) INDICATING "CLICK
HERE TO SIGN", I AM ELECTRONICALLY SIGNING THIS DOCUMENT, WHICH WILL HAVE THE SAME LEGAL EFFECT
AS THE EXECUTION OF THIS DOCUMENT BY A WRITTEN SIGNATURE AND SHALL BE VALID EVIDENCE OF MY
INTENT AND AGREEMENT TO BE BOUND BY ITS TERMS.
robert bower 8/9/2021, 3:49 PM LOCAL TIME
({{Sig_es_:signer1:signature:dimension(width=50mm, height=8mm)}}) {{Dte_es_:signer1:dimension(width=70mm, height=8mm):font(size=10):calc(now()):format(date,'m/d/yyyy, h:nn tt "LOCAL TIME"')}}

Named Insured's Signature Date

TXPIP-0317 (Pol #11407202227) Page 1 of 1

Dairyland County Mutual Insurance Company Of Texas

My.DairylandInsurance.com

TEXAS UNINSURED/UNDERINSURED MOTORISTS COVERAGE REJECTION

I have been given the opportunity to purchase or to reject as provided in Texas Insurance Code § 1952. I make the
following choice:

X I reject Uninsured/Underinsured Motorists Bodily Injury (UM/UIM-BI) Coverage in its entirety.

X I reject Uninsured/Underinsured Motorists Property Damage (UM/UIM-PD) Coverage in its entirety.

I fully understand UM/UIM-BI and UM/UIM-PD Coverage. I understand this rejection applies to this policy and
extension, renewal, change or reinstatement of it by the Named Insured unless the Named Insured subsequently
requests a change. It also applies to any reissuance of the policy by the Company. I also understand this rejection
applies to all vehicles insured under my policy. I understand I may add this coverage to my policy at a future date.
I ACKNOWLEDGE AND AGREE THAT BY CLICKING MY NAME ON THE DESIGNATED LINE(S) INDICATING “CLICK
HERE TO SIGN”, I AM ELECTRONICALLY SIGNING THIS APPLICATION, WHICH WILL HAVE THE SAME LEGAL
EFFECT AS THE EXECUTION OF THIS DOCUMENT BY A WRITTEN SIGNATURE AND SHALL BE VALID EVIDENCE OF
MY INTENT AND AGREEMENT TO BE BOUND BY ITS TERMS.

robert bower 8/9/2021, 3:49 PM LOCAL TIME

({{Sig_es_:signer1:signature:dimension(width=50mm, height=8mm)}}) {{Dte_es_:signer1:dimension(width=70mm, height=8mm):font(size=10):calc(now()):format(date,'m/d/yyyy, h:nn tt "LOCAL TIME"')}}

Named Insured's Signature Date

TXUM-0317 (Pol #11407202227) Page 1 of 1

 PREMIUM MUST BE PAID FOR COVERAGE TO BE IN FORCE
Vehicle(s) Covered
Year / Año 1995
Make / Marca SUZUKI
de Model / Modelo GSX-R1100W
VIN / Nùmero de Vehiculo
JS1GU75A4S2100598
Driver(s) Covered
BOWER, ROBERT B
This is part of your identification card, do not
detach.
Tarjeta de Seguro de
Responsabilidad Civil de Texas
Guarde esta tarjeta.
IMPORTANTE: Usted debe mostrar esta
tarjeta o una copia de su póliza de seguro
cuando solicite o renueve su:
Registro del vehículo motorizado
Licencia de conducir
Etiqueta de inspección de segurida para
su vehículo.
También se puede pedir que usted muestre
esta tarjeta o su póliza si tiene un accidente o
si se la pide un oficial de policía.
Todos los conductores en Texas deben de
tener seguro de responsabilidad para sus
vehiculos o de otra manera llenar los requistos
legales de responsabilidad civil. Fallo en llenar
este requisto pudiera resultar en multas de
hasta $1,000, suspensiòn de su licencia para
conducir y su registro de vehiculo de motor, y
la retenciòn de su vehiculo por unperiodo de
hasta 180 dias (a un costo de $15 por dia).
My.DairylandInsurance.com
Texas Liability Insurance Card
Insurance Company / Compañia de Seguro
Dairyland County Mutual Insurance Company Of Texas
Information Number 1-800-334-0090
Policy Number / Effective Date/Fecha Efectiva
Nùmero de Pòliza 08/09/2021
11407202227 Expiration Date/Fecha de Expiraciòn
08/09/2022
Year / Año 1995 Make / Marca SUZUKI
de Model / Modelo GSX-R1100W
VIN / Nùmero de Vehiculo JS1GU75A4S2100598
Agency / Agencia Agency /Agencia Phone #
ALC Insure Inc 361-578-7160
1803 N Navarro Street
Victoria TX 77901
Name and Address of Insured / Nombre y Direcciòn del Asegurado
BOWER, ROBERT B
417 HOLLY LN
VICTORIA TX 77905
This policy provides at least the minimum amounts of liability insurance
required by the Texas Motor Vehicle Safety Responsibility Act for the specified
vehicles and named insureds and may provide coverage for other persons and
vehicles as provided by the insurance policy.
Fold Here TX3000-0317
Texas Liability Insurance Card
Keep this card.
IMPORTANT: You must show this card or a copy of your insurance
policy when you apply for or renew
your:
Motor vehicle registration
Driver's license
Motor vehicle safety inspection sticker.
You may also be asked to show this card or your policy if you have an
accident or if a peace officer asks to see it.
All drivers in Texas must carry liability insurance on their vehicles or
otherwise meet legal requirements for financial responsibility. If you do
not meet your financial responsibility requirements, you could be fined
up to $1,000, your driver's license and motor vehicle registration could
be suspended, and your vehicle could be impounded for up to 180
days (at a cost of $15 per day).
THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY
WHILE YOUR INSURANCE REMAINS IN FORCE. THIS CARD NEITHER
AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
COVERAGE AFFORDED BY YOUR POLICY.
 PREMIUM MUST BE PAID FOR COVERAGE TO BE IN FORCE
Vehicle(s) Covered
Year / Año 1995
Make / Marca SUZUKI
de Model / Modelo GSX-R1100W
VIN / Nùmero de Vehiculo
JS1GU75A4S2100598
Driver(s) Covered
BOWER, ROBERT B
This is part of your identification card, do not
detach.
Tarjeta de Seguro de
Responsabilidad Civil de Texas
Guarde esta tarjeta.
IMPORTANTE: Usted debe mostrar esta
tarjeta o una copia de su póliza de seguro
cuando solicite o renueve su:
Registro del vehículo motorizado
Licencia de conducir
Etiqueta de inspección de segurida para
su vehículo.
También se puede pedir que usted muestre
esta tarjeta o su póliza si tiene un accidente o
si se la pide un oficial de policía.
Todos los conductores en Texas deben de
tener seguro de responsabilidad para sus
vehiculos o de otra manera llenar los requistos
legales de responsabilidad civil. Fallo en llenar
este requisto pudiera resultar en multas de
hasta $1,000, suspensiòn de su licencia para
conducir y su registro de vehiculo de motor, y
la retenciòn de su vehiculo por unperiodo de
hasta 180 dias (a un costo de $15 por dia).
My.DairylandInsurance.com
Texas Liability Insurance Card
Insurance Company / Compañia de Seguro
Dairyland County Mutual Insurance Company Of Texas
Information Number 1-800-334-0090
Policy Number / Effective Date/Fecha Efectiva
Nùmero de Pòliza 08/09/2021
11407202227 Expiration Date/Fecha de Expiraciòn
08/09/2022
Year / Año 1995 Make / Marca SUZUKI
de Model / Modelo GSX-R1100W
VIN / Nùmero de Vehiculo JS1GU75A4S2100598
Agency / Agencia Agency /Agencia Phone #
ALC Insure Inc 361-578-7160
1803 N Navarro Street
Victoria TX 77901
Name and Address of Insured / Nombre y Direcciòn del Asegurado
BOWER, ROBERT B
417 HOLLY LN
VICTORIA TX 77905
This policy provides at least the minimum amounts of liability insurance
required by the Texas Motor Vehicle Safety Responsibility Act for the specified
vehicles and named insureds and may provide coverage for other persons and
vehicles as provided by the insurance policy.
Fold Here TX3000-0317
Texas Liability Insurance Card
Keep this card.
IMPORTANT: You must show this card or a copy of your insurance
policy when you apply for or renew
your:
Motor vehicle registration
Driver's license
Motor vehicle safety inspection sticker.
You may also be asked to show this card or your policy if you have an
accident or if a peace officer asks to see it.
All drivers in Texas must carry liability insurance on their vehicles or
otherwise meet legal requirements for financial responsibility. If you do
not meet your financial responsibility requirements, you could be fined
up to $1,000, your driver's license and motor vehicle registration could
be suspended, and your vehicle could be impounded for up to 180
days (at a cost of $15 per day).
THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY
WHILE YOUR INSURANCE REMAINS IN FORCE. THIS CARD NEITHER
AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
COVERAGE AFFORDED BY YOUR POLICY.