INSURANCE

LINK
828 E.Hillsboro Blvd. Deerfield Beach, Fl. 33441

TO BE SUBMITTED WITH A P P L I C A T I O N :

02 21 2022

Wagner Douglas Cornelio

INSUREDS STATEMENT REGARDING UNDISCLOSED DRIVER(S),

HOUSEHOLD ME MBE RS AND RESIDENCY

I certify the following:

I have listed all residents of my household on the application for insurance.

I have listed all regular or occasional operators, who have either a driver's license or learners permit and
who may or may not reside in my household, on the application for insurance.

I understand that operators include those persons that currently have their driving privileges restricted,
suspended, revoked or are not licensed and drive my vehicle(s).

I acknowledge my responsibility to immediately add to my policy, by signed endorsement, anyone in the

future that becomes eligible as an operator as described above.

I acknowledge my responsibility to inform the company, by signed endorsement, anyone in the future
that becomes a resident of my household and eligible for benefits if in involved in an accident.

I acknowledge that I am aware that to be insured in the state of Florida all operators need to reside in
Florida at least 10 months per year.

I fully understand that my failure to comply with any of the above may cause my policy to be null and void
and could result in the denial of any claim.
The insurance carrier may deny the claim based on material misrepresentation. 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 have read and understand all the above stated information.

x
__________________________ Marcos Schilling
______________________________
Applicant Agent/CSR
INSURANCE
LINK
828 E Hillsboro Blvd – Deerfield Beach, FL 33441______________________________

REJECTION OF BODILY INJURY LIABILITY

The law in the state of Florida effective October 1, 1989 requires that you carry both Personal Injury Protection and Property Damage
Liability. The law also holds you responsible for any damages and/ or injuries you cause. Bodily Injury Liability coverage will pay damages
for injuries for which you become legally responsible because of an auto accident.

YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU, YOUR FAMILY
MEMBERS AND OTHERS USING YOUR VEHICLE SHOULD YOU CAUSE PHYSICAL INJURY TO ANOTHER PARTY IN AN
AUTOMOBILE ACCIDENT.

I hereby acknowledge that my right to purchase all auto coverage available in Florida has been fully explained to me. I acknowledge for
myself and any person who may be operating or responsible for the operation of any vehicle insured herein, that liability coverage for
Bodily Injury has been rejected and that this policy does not provide any coverage for the Florida Bodily Injury Financial Responsibility
requirements or for the bodily injury law requirements of any other state. If I decide to purchase this coverage at some future time, I must let
the Company, or my agent know in writing.

First Named Insured’s Signature x 02 21 2022

___________________________________________________________ Date: ____________________

NON – BUSINESS USE STATEMENT

Wagner Douglas Cornelio
Insured ___________________________________________ Code #: _____________________________

Company _________________________________________ Policy #: ____________________________

I HEREBY CERTIFY THAT MY _________________________________________________________________

(VEHICLES – YEAR, MAKE, MODEL)

IS (ARE) NOT USED FOR COMMERCIAL OR BUSINESS USE.

I FURTHER UNDERSTAND THAT IF THE ABOVE-MENTIONED VEHICLE(S) IS (ARE) INVOLVED IN AN

ACCIDENT RELATING TO BUSINESS USE THERE WILL BE NO COVERAGE AFFORDED ON THIS
POLICY.
X ________________________________________________

LETTER OF CONSENT

I _____ DO CONSENT I _____ DO NOT CONSENT

To receive from my insurance agent & their personnel electronic communication either by e-mail and/or
phone. Also, I agree that I am responsible for providing any updates to my e-mail address and/or mobile
phone number.
My most preferred method of electronic communication:

x
____Text Messaging
x Email
____

Wagnerdouglas90@icloud.com
Phone: ______________________________________E-mail: ___________________________________

Signature:X___________________________________________
 INSURANCE LINK 828 East Hillsboro Blvd Deerfield Beach,Fl.33441

Insurance Premium Financing

Disclosure Form
FLORIDA LAW REQUIRES THE OWNER OF A MORTOR VEHICLE TO MAINTAIN PERSONAL INJURY PROTECTION AND PROPERTY
DAMAGE LIABILITY INSURANCE UNDER CERTAIN CIRCUNMSTANCES AS IN CHAPTER 321, FLORIDA STATUTES, ADDITIONAL
LIABILITY INSURANCE MAY BE REQUIRED FOR BODILY INJURY LIABILITY. ALSO ADDITIONAL INSURANCE IS USUALLY REQUIRED BY
A LIENHOLDER OF A FINANCED VEHICLES FLORIDA LAW DOES NOT REQUIRE OTHER INSURANCE THE DIRECT OR INDIREDT PREMIUM
FINANCING OF AUTO CLUB MEMBER SHIPS AND OTHER NON-INSURANCE PRODUCTS IS PROHIBITED BY STATE LAW

Insurance you are REQUIRED by law to have:

Personal Injury Protection (PIP)…………………………………………………………….... $___________

Property Damage Liability (PD)……………………………………………………………… $___________

Commercial Auto Liability (BI/PD) ( ) - Personal Auto Liability (BI/PD) ( ) …………….. $___________

Other Insurance which you MAY be required by law to have:

Bodily Injury (If an SR-22 has been issued) ……………………………………..................... $___________

OPTIONAL Insurance Coverages:

Bodily Injury (If an SR-22 has NOT been issued) …………………………………………… $___________

Personal Auto Liability by Drive (BI/PIP/PD) ………………………………………………..$___________

Uninsured Motorist …………………………………………………………………………... $___________

Comprehensive ………………………………………………………………………………. $___________

Collision ……………………………………………………………………………………… $___________

Towing ( ) – Roadside Assistance ( ) – Rental Reimbursement ( )……………………… $___________

Accidental Death & Dismemberment (AD&D)……………………………………………… $___________

Travel Program (NSD)………………………………………………………………….……...$___________

Motors Vehicle Record Fee (MVR) …………………………………………………….…… $___________

Policy Fee (If applicable)………………………………………………………………….…. $___________

…………………………………………………………………………………………….…...$___________

Convenience Fee... ……………….......................................................................................... $___________

………………………………..…… ….……………………………………………….….. $___________

Figa Fee (If applicable)…………………………………………………………………..…….…. $___________

TOTAL INSURANCE PREMIUMS……………………………………………………..…...….. $___________

Less Down Payment Applied…………………………………………………………………..…. $___________

Amount Financed (LOANED TO YOU)…………………………………………………………. $___________

Wagner Douglas Cornelio
I, ________________________________________________ have read the above and understand the coverage
I am buying and how much they cost.

____________________________________________________________________ Date: _____/_____/________

02 21 2022

Signature of Insured
 Signature Certificate
Envelope Ref: f6e602d59b4195ca40446dc38f62f9147fa76f8d

Author: Marcos Schilling Creation Date: 18 Feb 2022, 18:20:13, EST Completion Date: 21 Feb 2022, 08:37:33, EST

Document Details:

Name: All 4 Forms Combination( Auto)

Type:

Document Ref: af3f0cdea755c2931ef3efa1841507767ad93813241fd63e73292

b56f8ef86f4

Document Total 3
Pages:

Document Signed By:

Name: Wagner Douglas Cornelio

Email: Wagnerdouglas90@icloud.com
IP: 2601:589:4b80:75c0:4bf:fb6f:614f:3d3f
Date: 21 Feb 2022, 08:37:33, EST
Consent: eSignature Consent Accepted
Security Level: Email, SMS

Document History:

Envelope Created Marcos Schilling created this envelope on 18 Feb 2022, 18:20:13, EST
Invitation Sent Invitation sent to Wagner Douglas Cornelio on 18 Feb 2022, 18:22:40, EST
Invitation Accepted Invitation accepted by Wagner Douglas Cornelio on 21 Feb 2022, 08:36:53, EST
Signed By Wagner Douglas Wagner Douglas Cornelio signed this envelope on 21 Feb 2022, 08:37:33, EST
Cornelio
Executed Document(s) successfully executed on 21 Feb 2022, 08:37:33, EST
Signed Document(s) Link Emailed to Wagnerdouglas90@icloud.com
Signed Document(s) Link Emailed to info@insurancelink.us