Car Insurance Usa

DocuSign Envelope ID: FFB2CAA4-B533-451C-90F8-67E6013B385B
Underwritten by: Bristol West Insurance Company

FAX COVER SHEET
(For Agent Use)
Bristol West Insurance Company
From: 3723844 To:
OPTIONS INSURANCE AGENCY Pennsylvania Unit
164 LINCOLN HWY STE 205
FAIRLESS HILLS PA 19030-1000 Phone # 1-888-888-0080 option 3
Phone: 717-340-6290 Fax # 1-888-888-0070
Fax: 215-839-3948
DATE: 12/08/2021 TIME: 03:28 ET TRANSACTION: New Business

INSURED: HARYADI HARYADI POLICY #: G01 1488229 00 EFF. DATE: 12/08/2021
INCLUDED DOCUMENTS:
Go Paperless – In order to complete enrollment in Go Paperless the customer must complete the following steps within 14 days of policy
upload:
• Open authentication e-mail sent to customer e-mail account.
• Click on authentication link in e-mail.
• Log in and register on foremost.com by creating a username and password. The insured will need to have their policy number
handy.
• Click and accept the Terms and Conditions for Go Paperless.
Please note: It may be necessary for the customer to check the SPAM/JUNK folder of their e-mail account to receive the authentication
e-mail. To avoid future Go Paperless e-mails ending up in the SPAM/JUNK folder the customer may need to adjust their SPAM settings and
should add Bristol West Insurance to their e-mail contact list.
Proof of Prior Insurance:

Your rate has increased because we found prior insurance with a Farmers affiliated company. You can dispute this by uploading the
policy and submitting valid proof of prior insurance with another which may result in an adjustment to your rate. Please see your agent
guide for further details and possible exceptions.
Excluded Driver(s)
Please provide "Proof of Suspended License" or "Proof of Other Insurance".
MINIMUM PAGES INCLUDING THIS COVER: _# of docs + 1_

Underwritten by:
BRISTOL WEST INSURANCE COMPANY (33)
PO BOX 31029, INDEPENDENCE, OH 44131-0029
POLICY NUMBER: G01 1488229 00
Rates Effective Date 07/29/2021
NAMED INSURED PRODUCER INFORMATION

HARYADI HARYADI OPTIONS INSURANCE AGENCY
901 PATTON DR 164 LINCOLN HWY STE 205
CARLISLE, PA, 17013-1657 FAIRLESS HILLS, PA, 19030-1000
email address: umiharyadi17@gmail.com
Home: 717-609-9815 Producer Code: 3723844
Work:
*Must reside in Pennsylvania at least 10 months during the year
POLICY INFORMATION
EFFECTIVE DATE: 12/08/2021* TOTAL PREMIUM: $462.00
EXPIRATION DATE: 06/08/2022 DOWN PAYMENT: $472.00
UPLOAD DATE: 12/08/2021 PAYMENT RECEIVED: $472.00
* later of 12:01 am or the time application is executed
DRIVER AND RESIDENT INFORMATION

The applicant, spouse and all household residents 15 years of age or older, all operators of the vehicles described in this application and all
children who live away from home who drive these vehicles, even occasionally, are listed below.
# NAME DOB SEX Marital Status License Status Relationship Driver Status
1 HARYADI HARYADI 1971 M M Valid FDL Insured Rated
2 UMI KALSUM 1973 F M Non-Licensed Spouse Excluded
VEHICLE INFORMATION
AT LEAST ONE VEHICLE MUST BE GARAGED IN PENNSYLVANIA 10 MONTHS OF THE YEAR
# YEAR/MAKE/MODEL VIN USE GARAGING ZIP
1 2013 VOLKSWAGEN JETTA BASE S SD 3VW2K7AJ3DM351861 Pleasure 17013
AUTO INSURANCE HISTORY
Bristol West, policy number: 33G011080698 Continually insured for less than 12 months
No prior insurance
PREMIUM DISCOUNTS
Paid In Full, Go Paperless,
App 001 (05/19)

Date: 12/08/2021 Page 2
PREMIUM BY VEHICLE
Vehicle 1: 2013 VOLKSWAGEN JETTA BASE S SD

VIN: 3VW2K7AJ3DM351861
Discounts applied to Vehicle: Double Air Bag
Coverage Limit Per Person Limit Per Accident Deductible Premium

LIMITED TORT
BODILY INJURY LIABILITY $15,000 $30,000 $75.00
PROPERTY DAMAGE LIABILITY $5,000 $122.00
MEDICAL EXPENSE $5,000 $33.00
UNINSURED MOTORISTS Rejected
UNDERINSURED MOTORISTS Rejected
COMPREHENSIVE $1000 $28.00
COLLISION $1000 $163.00
RENTAL REIMBURSEMENT $12.00
( $20 PER DAY / 30 DAYS MAXIMUM)
Total Premium for 2013 VOLKSWAGEN JETTA BASE S SD $433.00
TOTAL POLICY PREMIUM

Vehicle Subtotal (all vehicles) $433.00
Policy Fee $29.00
Grand Total (Semi-Annual) $462.00
Service Fees Not included in Total Premium: Excluded Driver Fee: $10.00
App 001 (05/19)

Date: 12/08/2021 Page 3

DECLARATIONS OF APPLICANT
(Insured MUST initial all items)
1) <BW.NI1.I>
All of the following drivers are declared on the application:
a. All regular operators (operates vehicles more than 60 days per year)
b. All licensed household members (including permit drivers)
c. All household members of legal driving age (including children away from home or in college)
2) <BW.NI1.I>
None of the drivers declared on this application have been convicted of insurance fraud
3) <BW.NI1.I>
All drivers that are listed on this application permanently reside in Pennsylvania.
4) All vehicles listed on this application are titled and registered in Pennsylvania. All vehicles listed on
<BW.NI1.I>
this application are garaged in Pennsylvania at least (10) months a year.
5) The garaging address listed for each vehicle on this application is a residential address where the
<BW.NI1.I>
vehicle is principally garaged.
6) None of the vehicles listed on this application are used for pick-up or delivery of goods (including but
<BW.NI1.I>
not limited to pizza, mail, magazines, newspapers, or farm produce); used for racing, used for limousine, taxi, or
emergency services; used in Personal Vehicle Sharing Program, Commercial Ridesharing Program or similar
arrangement, or used for courier or escort services.
7) <BW.NI1.I>
None of the vehicles listed on this application have snowplowing equipment.
8) <BW.NI1.I>
None of the vehicles listed on this application have a salvage title or have been previously deemed a
total loss.
9) <BW.NI1.I>
I have disclosed all vehicles with business use defined as:
a. Used to make trips for business purposes more often than 15 days in one month or 90 days in a 6 month
period or 180 days in a year;
b. Owned or leased by a business or has a business as an additional interest;
c. Owned or leased by an operator who receives a monthly allowance for the vehicle.
10) I UNDERSTAND THAT IF I RESIDE IN NEW YORK OR NEW JERSEY I DO NOT QUALIFY FOR
<BW.NI1.I>
THIS PENNSYLVANIA POLICY.
App 001 (05/19)

Date: 12/08/2021 Page 4
By signing below, I declare that I have read the statements above and that such statements are true. By signing
below, I further declare that I will notify my Producers should any information on this application change during the
policy period. I further agree and declare that the policy of insurance, as set forth in the application, is null and void
if the statements listed above prove to be false at any time during the policy period.
12/8/2021
<BW.NI1.S> <BW.NI1.DS>
Signature of Named Insured Date
App 001 (05/19)

Date: 12/08/2021 Page 5
IMPORTANT NOTICE
The laws of the Commonwealth of Pennsylvania, as enacted by the General Assembly, only require that you purchase
liability and first party medical benefit coverages. Any additional coverages or coverages in excess of the limits required
by law are provided only at your request as enhancements to basic coverages.
The minimum limits mandated by the Commonwealth of Pennsylvania are: Bodily Injury Liability - $15,000 for one person
in any one accident / $30,000 for two or more persons in any one accident; Property Damage Liability - $5,000; and
Medical Benefits- $5,000. Your premium for these basic coverages is:
Bodily Injury: $77.00

Property Damage: $120.00
Medical Expense: $32.00
Total $229.00
APPLICANT STATEMENT:
I hereby apply to Bristol West Insurance Company (“Company”) for a policy of insurance as set forth in this application,
based on my statements, representations and promises contained herein. I declare that these statements,
representations and promises are true to the best of my knowledge. I agree that such policy shall be canceled and claims
denied at inception if I provide information that is false or misleading or if I omit information that would materially affect
acceptance of the risk by Company. I agree that such policy shall be null and void if I provide information that is false or
misleading or if I omit information that would materially affect acceptance of the risk by Company.
I agree that an inquiry may be made which will provide applicable information as to my character, reputation, personal
characteristics, mode of living, location of residency and garaging address, driving record, vehicle history, and financial
responsibility history or financial responsibility based insurance score. I agree to allow Company to share my name,
address, date of birth and social security number with third party consumer reporting and insurance support organizations
in order to obtain consumer reports. I authorize the Company to obtain such reports for this policy, renewals, or for any
claim. I understand that this authorization will remain in effect for the full policy term. I agree to pay any additional
premium which is charged based upon information disclosed by these reports. I acknowledge that I may contact the
Company to access this information, request a copy of this authorization form and correct information that is inaccurate, in
accordance with the Company’s procedures. Further information on these reports is provided in the policy package.
In connection with this application for insurance, my financial responsibility score is used as a factor in determining my
premium. I understand that the Company may review my financial responsibility report to determine my financial
responsibility score. I authorize the Company to obtain my financial responsibility report and/or financial responsibility
score, and I understand that a third party may be used in connection with the development of my financial responsibility
score.
Address Verification: I understand that in connection with this application for insurance, I provided my mailing address
and the garaging address of my vehicle(s). These addresses are one of the factors that the Company uses to underwrite
and/or rate my policy. I understand that the Company will review third-party reports (including my credit report) to verify
the accuracy of my self-reported addresses. I also understand that the company will use the discrepancy between any of
these addresses as a factor in determining my policy premium.
App 001 (05/19)
Date: 12/08/2021 Page 6

Driving Score: I understand that in connection with this application for insurance, the Company may utilize a third party to
obtain a driving score based on vehicle data such as hard braking, acceleration, and speeds above 80 mph. If available, I
authorize the Company to obtain this information and use my driving score as a factor in determining my premium.
Additional Equipment: I understand that if I purchase Comprehensive and Collision Coverage, coverage will automatically
be provided up to $1000 for damage to additional equipment. I understand that I have the option to Additional Equipment
Coverage at higher limits in excess of the $1000. Coverage for additional equipment is based on the actual cash value of
the additional equipment. Additional equipment means permanently installed or attached custom parts, equipment,
devices, accessories, enhancements, and changes that alter the appearance or performance of a covered auto and that
were not installed by the original automobile manufacturer. Additional equipment includes, but is not limited to,
permanently installed stereo equipment, custom paint and exterior body panels, custom wheels and tires, equipment to
modify vehicle height on both raised and lowered vehicles, custom seats, and safety or alarm devices.
If the down-payment (initial premium payment) accompanying this application is not honored by my financial institution, I
understand and agree that this policy will be void at inception and I will not be afforded any coverage whatsoever except
as otherwise provided by Pennsylvania law.
I understand and agree that my premium down-payment for this application may be used to reduce any previous balance
I owe the Company. I further understand that any claim payment due to me under this policy may be reduced by any
balance I owe the Company.
I agree to pay an installment fee of $12.00 per installment that becomes due during the policy term and during each
renewal policy term in accordance with the payment plan I have selected. Should I choose to pay by direct debit
(electronic funds transfer), I agree that the installment fee will be $8.00 per installment. I understand that the amount of
these fees may change if I change my payment plan.
I agree that I will be charged a fully-earned policy fee of $29.00 less any adjustments related to anti theft device
discounts, passive restraint discounts and driver improvement course discounts that may apply, at the inception of my
policy term and at each renewal thereafter.
I agree that a service charge of $20.00 will be assessed to the balance due on my policy if any check or direct debit
(electronic funds transfer) offered in payment of an installment is not honored by my financial institution. The imposition of
such charge does not constitute acceptance of the check by the Company and is without prejudice to any other rights of
the Company.
I agree to pay a late fee of $10.00 during the policy term and each renewal policy term when the amount due under an
installment payment is not received in full by the premium due date.
If the Company reinstates my policy for any reason, I agree that all coverage elections and rejections and driver
exclusions, if any, made with this Application shall apply to any policy reinstatement and to any renewal, continuation,
amended, altered, modified, substitute or replacement policy with this company or any affiliated company.
I understand that I will be charged a $25.00 Cancellation Fee if I cancel this policy for any reason or if Company cancels it
due to my failure to pay any premium when due. This fee is in addition to any premium the Company has earned for the
coverage provided by this policy and may be deducted from any refund to which I am entitled.
I agree that I will be charged a fully-earned fee of $10.00 when there is an Excluded Driver listed on the policy. This fee
will only be charged once per policy term, regardless of the number of excluded drivers on the policy.
I agree that I will be charged a fully-earned fee of $3.00 when there is a Loss Payee or Additional Interest listed on the
policy. This fee will only be charged once per policy term.
I agree that I will be charged a fully-earned fee of $4.00 if I do not select the Go Paperless feature.
App 001 (05/19)

Date: 12/08/2021 Page 7
I agree to pay a Convenience Fee of $0.00 for each and every payment that I make by calling into customer service/service
operations to process a one-time payment.
I agree to pay a Convenience Fee of $0.00 for each and every payment that I make by calling into the Company’s Interactive
Voice Response (IVR) system to process a one-time payment.
FEE POLICY:
I agree that the amount of any fee charged under this policy may change with any renewal of this policy and that the
Company retains the right to change the amount, terms or conditions of the assessment of any fee with any renewal of this
policy. I understand that if the Company changes the amount, terms or conditions of the assessment of any fee listed above,
they will notify me of these changes in their offer to renew my policy. I further understand that I am required to pay all fees
assessed under this policy and my failure to pay any such fee may result in the cancellation of my policy for nonpayment of
premium, the assessment of additional fees or the possibility of my account being assigned to a collections bureau.
GO PAPERLESS CONSENT:
If I elect to enroll in the Go Paperless option, I agree to access my insurance policy documents electronically in lieu of
delivery by U.S. Mail or other physical delivery method; provided, however, that, as required by law, the Company will deliver
certain insurance policy documents, such as cancellation and nonrenewal notices, in paper format via U.S. Mail. I agree to
read the Terms and Conditions relating to the Go Paperless option carefully and, by electing to enroll in the Go Paperless
option, I agree to be bound by them.
I agree that my enrollment into the Go Paperless is contingent upon me providing a valid e-mail address to the Company.
Shortly after I apply for coverage the Company will verify my e-mail address by sending me an "authentication e-mail" to the
e-mail address I provided the Company. I agree that I must complete the Company’s authentication and registration process
to complete my enrollment into Go Paperless. I further understand that I have the ability to “opt-out” of the Go Paperless
option. Should I opt-out, I agree that I will not receive a Go Paperless discount, if applicable.
E-MAIL CONSENT:
I agree that by providing my e-mail address to the Company, I hereby give the Company, and its affiliates, consent to send
information regarding my policy to the e-mail address listed on this application. I understand that this information may
include, but is not limited to: premiums due under my policy, the status of my policy and renewal information regarding this
policy. I understand that the Company and its affiliates will not sell or furnish my e-mail address to any non-affiliated third
party and that I may opt out of receiving e-mail by notifying the Company of my intent.
I agree that the Company and its affiliates may use any telephone number I provide now or in the future to contact me by way
of live calls or by use of any automatic dialing system or artificial or prerecorded voice.
I understand that the statements and representations made on this application will become a part of my policy. I further
understand that coverage will not be effective any earlier than the date and time the application is bound by my producer,
signed by me and the premium paid.
I acknowledge that I have received a copy of my new business documents (and all applicable attachments), my policy
contract and this application. If I have elected the Go Paperless option, I agree to access certain insurance policy documents
electronically after I obtain my coverage.
App 001 (05/19)

Date: 12/08/2021 Page 8
<BW.NI1.I>
TEXT ALERTS CONSENT:
If I elect to enroll in the Text Message Alert Program, I consent to receive text messages regarding the servicing of my
policy(ies) from or on behalf of the Company and its affiliates at the mobile number(s) I have provided. By enrolling in the
Text Message Alert Program, I acknowledge and agree to the following:
• I am an authorized user of the mobile phone number(s) provided;
• My enrollment in the Text Message Alert Program will remain in effect until I revoke consent in accordance with the
Company’s Terms and Conditions;
• The Text Message Alert Program may use an automatic telephone dialing system; and
• Enrollment in the Text Message Alert Program is not a condition of purchase.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
12/8/2021
am/pm
Signature of Applicant Date Time
PRODUCER SIGNATURE
The undersigned hereby warrants and certifies that the information contained herein is correct to the best of
his/her knowledge and that this application was completed and signed by the insured-applicant and that a copy of
the new business documents, this application and a copy of the policy contract has been provided to the
insured-applicant other than insurance policy documents accessed electronically via the Go Paperless option, if
applicable. Additionally, the undersigned Producer certifies that he/she is licensed in good standing under the
Insurance Code of Pennsylvania and duly appointed by the Company.
<BW.PA1.N> <BW.PA1.DS> am/pm
Producer Signature Date Time

<BW.PA1.LN>
MICHAEL WILLIAM WOODFORD <BW.PA1.S>
Producer Name (Print) Producer License No.
App 001 (05/19)

Date: 12/08/2021 Page 9
Pennsylvania Surcharge Disclosure Statement
In compliance with 75 Pa. C.S. Section 1793 (b), we provide this surcharge disclosure plan to explain our system of
driving record points. This statement provides an overview; more detailed information is available upon request.
Driving record points are assigned to operators for chargeable accidents and violations. All accidents and violations
occurring in the 35-month period prior to policy inception are considered in developing a driver’s policy premium. If a
driver is added mid-term, accidents and violations will be charged for the entire 35-month period prior to the driver
being added to the policy. Point surcharges follow the driver, and these surcharges remain in effect until they are no
longer in the experience period (the 35 months prior to the policy effective date). To determine if the accident or
violation took place in the chargeable period, we use the occurrence date instead of the conviction date. We charge for
accidents and violations occurring while a driver is operating a private passenger automobile.
Accidents. We assess a surcharge of approximately 30% for each at-fault accident charged to an operator. Accidents
are chargeable if, as a result of the accident, the insurer incurs at least $1,550 in losses (for accidents that occur prior
to 7/1/2017), $1,700 in losses (for accidents that occur on or after 7/1/2017 and before 7/1/2020), or at least $1,800 (for
accidents that occur on or after 7/1/2020) in excess of any deductible for personal injury or damage to property,
including the insured’s. Each accumulation of $1,550 in aggregate losses (for accidents that occur prior to 7/1/2017),
$1,700 in aggregate losses (for accidents that occur on or after 7/1/2017 and before 7/1/2020), or $1,800 (for losses
that occur on or after 7/1/2020) from incidents not otherwise charged represents an at-fault accident. If the insured can
demonstrate that any of the facts of loss described in 31 Pa. Code Section 67:33 (non-chargeable accidents) apply to
an accident, the accident will not be charged to the operator.
Minor Violations. We assess a surcharge of approximately 25% for the second and each subsequent conviction of
routine traffic infractions like speeding or failure to yield. Most of these infractions are listed in 75 Pa C.S. Section 1535.
Major Violations. We assess a surcharge of approximately 35% for each conviction of a violation which suggests the
presence of a materially increased risk in a motorist. Such major violations include vehicular homicide, leaving the
scene of an accident involving death or injury, or fleeing a police officer.
Driving While Intoxicated. We assess a surcharge of approximately 15% for each Driving While Intoxicated infraction
for conviction under Section 3731 (Driving under the influence of alcohol or controlled substance), notice of Section
1534 (Acceptance of Accelerated Rehabilitative Disposition), or any similar infraction.
SURCHDISC (07/20) Date: 12/08/2021 Page 10

Date 12/08/2021
Named Insured HARYADI HARYADI
Policy Number G01 1488229 00
Effective Date 12/08/2021
Effective Time 3:28 PM EST
REJECTION OF UNDERINSURED MOTORIST PROTECTION
By signing this waiver I am rejecting underinsured motorist coverage under this policy, for myself and all relatives
residing in my household. Underinsured coverage protects me and relatives living in my household for losses and
damages suffered if injury is caused by the negligence of a driver who does not have enough insurance to pay for all
losses and damages. I knowingly and voluntarily reject this coverage.
<BW.NI1.S>
Signature of First Named Insured
12/8/2021
<BW.NI1.DS>
Date
UIMELECT001 (02/12)
Date: 12/08/2021 Page 11
Date 12/08/2021
Named Insured HARYADI HARYADI
Policy Number G01 1488229 00
Effective Date 12/08/2021
Effective Time 3:28 PM EST
REJECTION OF UNINSURED MOTORIST PROTECTION
By signing this waiver I am rejecting uninsured motorist coverage under this policy, for myself and all relatives residing in
my household. Uninsured coverage protects me and relatives living in my household for losses and damages suffered if
injury is caused by the negligence of a driver who does not have any insurance to pay for losses and damages. I
knowingly and voluntarily reject this coverage.
<BW.NI1.S>
Signature of First Named Insured
12/8/2021
<BW.NI1.DS>
Date
UMELECT001 (02/12)
Date: 12/08/2021 Page 12
NOTICE OF TORT OPTIONS
The laws of the Commonwealth of Pennsylvania give you the right to choose either of the following two tort options:
A. ‘Limited Tort’ Option - This form of insurance limits your right and the rights of members of your household to seek
financial compensation for injuries caused by other drivers. Under this form of insurance, you and other household
members covered under this policy may seek recovery for all medical and other out-of-pocket expenses, but not for pain
and suffering or other non-monetary damages unless the injuries suffered fall within the definition of “serious injury” as
set forth in the policy, or unless one of several other exceptions noted in the policy applies.
B. ‘Full Tort’ Option - This form of insurance allows you to maintain an unrestricted right for yourself and other members
of your household to seek financial compensation for injuries caused by other drivers. Under this form of insurance, you
and other household members covered under this policy may seek recovery for all medical and other out-of-pocket
expenses and may also seek financial compensation for pain and suffering or other non-monetary damages as a result of
injuries caused by other drivers.
If you wish to change the tort option that currently applies to your policy, you must notify your agent, broker or company
and request and complete the appropriate form.
TORTNOTE001 (02/09)
Date: 12/08/2021 Page 13
NOTICE TO NAMED INSUREDS

TORT OPTION SELECTION
A. "Limited Tort" Option - The laws of the Commonwealth of Pennsylvania give you the right to choose a form of
insurance that limits your right and the right of members of your household to seek financial compensation for injuries
caused by other drivers. Under this form of insurance, you and other household members covered under this policy may
seek recovery for all medical and other out-of-pocket expenses, but not for pain and suffering or other nonmonetary
damages unless the injuries suffered fall within the definition of "serious injury" as set forth in the policy, or unless one of
several other exceptions noted in the policy applies. The annual premium for basic coverage as required by law under this
"limited tort" option is $459.00.
Additional coverages under this option are available at additional cost.
B. "Full Tort" Option - The laws of the Commonwealth of Pennsylvania also give you the right to choose a form of
insurance under which you maintain an unrestricted right for you and the members of your household to seek financial
compensation for injuries caused by other drivers. Under this form of insurance, you and other household members
covered under this policy may seek recovery for all medical and other out-of-pocket expenses and may also seek
financial compensation for pain and suffering and other nonmonetary damages as a result of injuries caused by other
drivers. The annual premium for basic coverage as required by law under this "full tort" option is $721.00.
Additional coverages under this option are available at additional cost.
C. You may contact your insurance agent, broker or company to discuss the cost of other coverages.
D. If you wish to choose the "limited tort" option described in paragraph A, you must sign this notice where indicated
below and return it. If you do not sign and return this notice, you will be considered to have chosen the "full tort" coverage
as described in paragraph B and you will be charged the "full tort" premium.
I wish to choose the "limited tort" option described in paragraph A:
12/8/2021
Named Insured Date
E. If you wish to choose the "full tort" option described in paragraph B, you may sign this notice where indicated below
and return it. However, if you do not sign and return this notice, you will be considered to have chosen the "full tort"
coverage as described in paragraph B and you will be charged the "full tort" premium.
I wish to choose the "full tort" option described in paragraph B:
Named Insured Date
TORTNOTE002 (02/09)
Date: 12/08/2021 Page 14
IMPORTANT NOTICE
Insurance Companies operating in the Commonwealth of Pennsylvania are required by law to make available for
purchase the following benefits for you, your spouse or other relatives or minors in your custody or in the
custody of your relatives, residing in your household, occupants of your motor vehicle, or persons struck by
your motor vehicle:
1. Medical Benefits, up to at least $100,000.
1.1 Extraordinary Medical Benefits, from $100,000 to $1,100,000 which may be offered in increments of
$100,000.
2. Income Loss Benefits, up to at least $2,500 per month up to a maximum benefit of at least $50,000.
3. Accidental Death Benefits, up to at least $25,000.
4. Funeral Benefits, $2,500.
5. As an alternative to paragraphs 1, 2, 3, and 4, a combination benefit, up to at least $177,500 of benefits

in the aggregate or benefits payable up to three years from the date of the accident, whichever occurs
first, subject to a limit on accidental death benefits of up to $25,000 and a limit on funeral benefits of
$2,500, provided that nothing contained in this subsection shall be construed to limit, reduce, modify or
change the provisions of Section 1715(d) (relating to availability of adequate limits).
6. Uninsured, Underinsured and Bodily Injury Liability Coverage up to at least $100,000 because of injury
to one person in any one accident and up to at least $300,000 because of injury to two or more persons in
any one accident or, at the option of the insurer, up to at least $300,000 in a single limit for these
coverages, except for policies issued under the Assigned Risk Plan. Also, at least $5,000 for damage to
property of others in any one accident.
Additionally, insurers may offer higher benefit levels than those enumerated above as well as additional
benefits. However, an insured may elect to purchase lower benefit levels than those enumerated above.
Your signature on this notice or your payment of any renewal premium evidences your actual knowledge and
understanding of the availability of these benefits and limits as well as the benefits and limits you have
selected.
If you have any questions or you do not understand all of the various options available to you, contact your
agent or company. If you do not understand any of the provisions contained in this notice, contact your agent
or company before you sign.
12/8/2021
Signature of First Named Insured Date
BENNOTE001 (02/09)
Date: 12/08/2021 Page 15
NAMED DRIVER EXCLUSION ENDORSEMENT ACKNOWLEDGMENT

By signing this form, I acknowledge my selection of the “Named Driver Exclusion” endorsement to be attached to, and
be part of, my personal automobile policy noted above. The “Excluded Driver (s)” listed on the endorsement are shown
below. I fully understand that I have received a lower insurance premium in exchange for my promise that the driver (s)
listed below will not drive any vehicle covered under the policy number listed below. I fully understand that by selecting
the “Excluded Driver” endorsement, that Bristol West Insurance Company will not provide coverage for the “Excluded
Driver (s)” or for me or any family member for any possible claim arising out of the below listed driver’s permissive or
non-permissive operation of any vehicle.
I understand that I can only designate a driver to be excluded if that driver is:
(1) Covered under a separate Personal Auto Insurance policy, or

(2) If that driver has a suspended license.
I agree that I will be charged a fully-earned Excluded Driver fee of $10.00 when there is an Excluded Driver listed on
the policy. This fee will only be charged once per policy term, regardless of the number of excluded drivers on the
policy.
Policy Number: G01-1488229-00
1.) UMI KALSUM DOB: 1973
12/8/2021
First Named Insured’s Signature Date
DREX 001 (01/17)

Date: 12/08/2021 Page 16
TOWBUSTERS WITH VEHICLES
LISTED
Home Office: Nation Motor Club, LLC., 800 W. Yamato Road, Suite 100, Boca Raton, FL 33431
MEMBER INFORMATION VEHICLE INFORMATION
Name Year Make Model
HARYADI HARYADI 1.
Address
901 PATTON DR 2.
City State Zip
CARLISLE PA 17013 3.
SELLER INFORMATION
Business Name User ID 4.
OPTIONS INSURANCE AGENCY
Address 5.
1900 SAND HILL RD MEMBERSHIP INFORMATION
City State Zip Effective Date Expiration Date Membership Fee
HERSHEY PA 17033 12/8/2021 6/8/2022 $80.00
For Emergency Roadside Assistance Only Call 1-800-745-5791

Member #: NRDE13799350
Producer Code: 107024
Plan Letter: B
For Customer Service Only Call 1-888-684-9327, Monday through Friday, from 8:30 am - 5 pm eastern time
THIS IS NOT AN INSURANCE CONTRACT.

This is not an Automobile Physical Damage or Automobile Liability insurance contract.
Your Membership contains Our 24 hour emergency road service telephone number for You to call when Your Covered Vehicle is disabled. When arranging
for Roadside Assistance, please call 1-800-745-5791 and reference Your Producer Code, Member Number and Plan Letter (located above). You will not be
required to pay any additional fee or sum in addition to the Membership Fee when Your service is for a tow up to fifteen (15) miles or other covered service
listed below. You are entitled to one (1) covered service within a seventy two (72) hour period. Covered services not obtained through Us are limited to a
maximum reimbursement amount of fifty dollars ($50).
Towing - Up to fifteen (15) miles at no out of pocket expense to You. Additional mileage is available and will be negotiated prior to sending out a service
vehicle. Additional mileage is to be paid by You directly to the service provider at the time of service.
Mechanical First Aid: Any minor adjustment that a dispatched service provider might perform to allow Your Covered Vehicle to proceed safely under its
own power.
Tire Service: Includes changing a flat tire with Your good spare.
Battery Service: Jumpstart or boost a dead battery.
Delivery Service: Including gasoline, water, oil, or any supplies necessary to send Your Covered Vehicle on its way. You are responsible for the actual
cost of fluid and/or supplies delivered.
Lockout Services: We will send a locksmith if You are accidentally locked out of Your Covered Vehicle. Access to passenger compartment only.
Limit: No more than five (5) service calls within the contract period
RENTAL REIMBURSEMENT
You will be reimbursed for automobile rental expenses incurred if repair work to the Covered Vehicle is necessitated by reason of an accident with another
vehicle which occurred while this Membership is in effect. Reimbursement for Auto Rental shall be for an amount of up to fifteen dollars ($15) a day for up to
five (5) days during each membership period. For each occurrence, eligibility for reimbursement shall not commence until the second (2nd) day of such auto
rental. If You are reimbursed by any insurance carrier, We are not responsible to reimburse You. Please be advised that We will only reimburse during the
repair period and We cover the rental reimbursement only (this does not include taxes, insurance or any other surcharges which may be incurred at the time of
rental). It is hereby agreed and understood that this Membership will be excess of any other valid and/or collectables coverages.
Claim Procedures: You must call Us at 888-684-9327, Monday through Friday, 9 am - 5 pm eastern time, within sixty (60) days of the incident. You will be
provided with a claim form which You must complete and send back to Us along with the following: (a) police report; (b) original receipted bill from licensed
auto rental agency; (c) receipted bill from repair service showing repaired car was released to You; (d) repair estimate from repair facility; (e) statement from
the auto dealer showing that the repairs were made, the date the car came in for repair, and the date the car was released to You; (f) any other documentation
that We reasonably request. We will only reimburse You for rental expenses that were incurred during the reasonable repair period.
Our Right to Recover Payment: If We make a payment under this Membership and You have the right to recover damages from another, You must: (a)
Hold in trust for Us the proceeds of the recovery; (b) Reimburse Us to the extent of Our payment; and (c) Not prejudice Our rights to recover.
ADDITIONAL BENEFITS
Theft Hit & Run Protection: We will pay a person, (excluding Member or Member's family) five hundred dollars ($500) for information leading to the
arrest and conviction of a person for the theft of a Your Covered Vehicle or tagged valuable articles.
Rental Car Discounts: You may access car rental discounts for: NATIONAL (1-877-222-9058 ID# XZ41148 PIN# NSD);
THRIFTY (1-800-367-2277 ID# 0010027892); and ENTERPRISE (1-800-736-8222 ID# XZ41148 PIN# NSD)
Concierge Benefits: You may contact Our Concierge center at 1-855-963-1683, and give the producer code number listed on the front of this Agreement,
twenty four (24) hours a day / seven (7) days a week, to speak with a representative who will assist You with the following concierge services: a)
emergency message relays to family friends or co-workers; b) hotel and rental car availability; c) ATM locations; d) locate medical facilities; e) theme park
and local attraction information; f) restaurant locations; g) movie schedules and locations; h) directional assistance; i) traffic alerts; and j) sport scores.
Please note: Services provided are for informational purposes ONLY. You are responsible for making any/all payment arrangements and for setting up
benefits that require additional billing, such as the actual cost of hotel rooms, rental cars, etc. Payment is to be made directly by You to the providers,
vendors or establishments.
TB 10/14 Page 1 of 3 131 r0318

TERMS AND CONDITIONS
You, Your, Member means the individual(s) listed in the registration section of this Membership;
We, Us or Our means the Provider/Administrator of the Motor Club benefits and services;
Covered Vehicle means the vehicle(s) listed in the registration section of this Membership;
All benefits are available to You up to Your benefit limit, as described throughout this Membership, without any additional payments. You are responsible for any
non-covered expenses;
Your Membership begins on the Effective Date as shown above and continues until the Expiration Date, unless cancelled.
All of the benefits and services of Your Motor Club Membership are described herein and are applicable throughout the United States, Canada and Puerto Rico;
All services and benefits are Administered through Nation Motor Club, LLC. dba Nation Safe Drivers located at 800 W. Yamato Road, Suite 100, Boca Raton, FL 33431. In
California: All services and benefits are Administered through Nation Motor Club, LLC. located at 800 W. Yamato Road, Suite 100, Boca Raton, FL 33431. California Motor
Club Permit Number: 5157-3. In Alabama, Alaska & Utah: All services and benefits are Administered through Nation Safe Drivers Services, Inc.;
For Customer Service please contact the Administrator at 888-684-9327, Monday through Friday, from 8:30 am - 5 pm eastern time;
All claims must be reported to the Administrator at 800 W. Yamato Road, Suite 100, Boca Raton, FL 33431; 888-684-9327;
You have the right to file a complaint by submitting a written complaint to Our Customer Service Department at 800 W. Yamato Road, Suite 100, Boca Raton, FL 33431 or
by calling 1-888-684-9327, Monday through Friday, from 8:30 am - 5 pm eastern time;
You may obtain a full copy of Our company's privacy notice by sending a written request to the Administrator, Attention: Privacy Notice Department, 800 W. Yamato Road,
Suite 100, Boca Raton, Florida 33431.
EXCLUSIONS
This Membership does not cover the following: a) Any violation of motor vehicle or traffic laws relating to the operation of a motor vehicle; b) Driving under the influence of
intoxicating liquors, narcotics or psychedelic drugs; c) Driving without a valid operator's permit, or leaving the scene of an accident without disclosing identity, or failing to stop
to ascertain injury and lend assistance (i.e. hit and run); d) When any motor vehicle is operated without permission of the owner thereof; e) Service for trucks in excess of one ton
chassis, busses, trailers, tractors, or vehicles of dual wheel class; f) Any service requiring removal of snow or ice from or around Your Covered Vehicle(s), or from any
driveway or premises, or street, highway or parking area; g) Gas/credit card receipts are not accepted; h) Reimbursement sought for any bill which, in Our opinion appears to be
false or fraudulent, and not for the claimed services; i) Any parts of the Covered Vehicle, rental battery or return of rental battery. Supplies or accessories furnished by garage
or service station shall be at the sole expenses of the Member; j) All repairs and material used in repairing flat tire, or services requiring more than one trip by garage or service
station shall be at the sole expense of the Member; k) By being involved in any traffic accident or any accident involving a motor vehicle in which a Police Traffic Accident
Report is not filed or made a matter of record; l) In which You or any person intentionally causes damage to the Covered Vehicle; drives in any competition, race or speed
contest or in preparation for same; or causes any accident while committing or attempting to commit a felony or other illegal act including but not limited to fleeing from police;
m) Due to war or any warlike act, whether war is declared or not, terrorism, acts of God or vandalism.
CANCELLATION
If this Membership is cancelled by You within thirty (30) days from the Effective Date, You will receive a refund of the full purchase price, less the amount of any claims paid
or payable. If You cancel this Membership after the first thirty (30) days, You will be refunded by the Administrator on a prorated basis, less a cancellation fee of fifty
dollars ($50) and the amount of any claims paid or payable. All cancellation requests must be submitted in writing to the Administrator and signed by You.
TRANSFER
This Membership cannot be transferred.
STATE PROVISIONS
The following state specific requirements apply if Your Membership was purchased in one of the following states:
ARKANSAS
The Our Right to Recover Payment section is modified as follows: If We make a payment under this Membership and You have the right to recover damages from another, You
must: (a) Hold in trust for Us the proceeds of the recovery; (b) Reimburse Us to the extent of Our payment; and (c) Not prejudice Our rights to recover. We will be entitled to
recovery only after You have been fully compensated for the loss sustained.
CALIFORNIA
The Theft Reward benefit is replaced in its entirety by the following: We will pay a person, (excluding Member's family or relatives) five hundred dollars ($500) for
information leading to the arrest and conviction of a person for the theft of a Member's Covered Vehicle(s).
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days from the Effective Date,
You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, the amount of the refund will be prorated based on the number
of days remaining on the contract term. The refund will be payable to You or the Lienholder when financing has been provided for the Membership. All cancellation requests
must be submitted in writing to the Administrator and signed by You. Whether this Agreement is cancelled by You or the Administrator, a cancellation fee or the amount
of claims incurred or paid will not be deducted from any returned premiums.
Other Offices: Nation Motor Club, LLC., 818 West Seventh Street, Los Angeles, CA 90017
LOUISIANA
You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be refunded on a prorated basis, less a cancellation
fee of twenty five dollars ($25). All cancellation requests must be submitted in writing to the Administrator and signed by You.
MARYLAND
You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be refunded on a prorated basis. All cancellation
requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 351 West Camden Street, Baltimore, MD 21201; (410) 225-2995
MASSACHUSETTS
MISSISSIPPI
Other Offices: Nation Motor Club, LLC., 645 Lakeland East Drive, Suite 101, Flowood, MS 39232
MONTANA
Other Offices: Nation Motor Club, LLC., 208 North Broadway, Suite 313, Billings, MT 59404
NEVADA
Other Offices: Nation Motor Club, LLC. dba Nation Safe Drivers, 311 South Division Street, Carson City, NV 89703
TB 10/14 Page 2 of 3
NEW MEXICO
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days from the Effective
Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be refunded on a prorated basis. All
cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 123 East Marcy, Santa Fe, NM 87501
NEW YORK
The Rental Reimbursement benefit in this Membership is not applicable.
OKLAHOMA
The Cancellation section of this Membership is replaced in its entirety by the following: This Membership can be cancelled by You or the Administrator at any time. You will
be entitled to the unused portion of the amount paid for the Membership calculated on a prorated basis over the period of the contract, without any deductions. The refund will
be payable to You or the Lienholder, where applicable. All cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 1833 South Morgan Road, Oklahoma City, OK 73128
TENNESSEE
The Theft Hit & Run Protection benefit in this Membership is not applicable.
UTAH
The Cancellation section of this Membership is replaced in its entirety by the following: You may cancel this Membership within the first ten (10) days of the purchase date, if
no claim has been made, and receive a full refund of the total Membership purchase price, less the applicable cancellation fee in the amount of fifty dollars ($50). We may only
cancel this Membership under the following grounds: (1) Material misrepresentation; (2) Substantial change in the risk assumed, unless the insurer should reasonable have
foreseen the change or contemplated the risk when entering into the Membership; (3) Substantial breaches of contractual duties, conditions, or warranties attainment of the age
specified as the terminal age for coverage. If this Membership is canceled due to non-payment, We will mail written notice of cancellation to You and will cancel Your
Membership no sooner than at least ten (10) days after the delivery or first-class mailing of a written notice. If this contract is canceled for any of the reasons listed above, We
will mail written notice of cancellation to You and will cancel Your Membership no sooner than thirty (30) days after the delivery or first-class mailing of a written notice. If
the Administrator cancels this Membership at any time, You will be entitled to prorated refund of the Membership less a cancellation fee of fifty dollars ($50). In general, if
Administrator cancels this Membership, Administrator will mail to You written notice of cancellation at least thirty (30) days before the cancellation date. However, if
Administrator cancels this Membership within the first sixty (60) days after the Membership purchase date, Administrator will mail to You written notice of cancellation at
least ten (10) days before cancellation date.
WISCONSIN
Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be refunded on a prorated basis, less a
cancellation fee of twenty five dollars ($25). All cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 8040 Excelsior Drive, Suite 200, Madison, WI 53717
WYOMING
Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be refunded on a prorated basis. All
cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 1712 Pioneer Avenue, Suite 200, Cheyenne, WY 82001
Lauren Smith, Secretary 10/15
By Your signature below, You acknowledge and agree that Your acceptance of this Membership is voluntary. It is understood by the undersigned that coverage afforded under
this Membership applies only to the Covered Vehicle listed in the registration section of this Membership. This Membership does not comply with the financial responsibility
or no-fault laws of any state or territory.
12/8/2021
Signature of Member(s) Date
12/8/2021
Signature of Seller Date
TB 10/14 Page 3 of 3
Certificate Of Completion
Envelope Id: FFB2CAA4B533451C90F867E6013B385B Status: Completed
Subject: HHaryadi_G01148822900_UnsignedApp
Source Envelope:
Document Pages: 19 Signatures: 8 Envelope Originator:
Certificate Pages: 4 Initials: 11 Options Insurance
AutoNav: Enabled 1900 sandhill road
EnvelopeId Stamping: Enabled Hershey, PA 17033
Time Zone: (UTC-05:00) Eastern Time (US & Canada) esignhershey@gmail.com
IP Address: 71.173.197.200
Record Tracking
Status: Original Holder: Options Insurance Location: DocuSign
12/8/2021 4:14:09 PM esignhershey@gmail.com
Signer Events Signature Timestamp

Haryadi Haryadi Sent: 12/8/2021 4:17:24 PM
umiharyadi17@gmail.com Viewed: 12/8/2021 4:23:02 PM
Security Level: Email, Account Authentication Signed: 12/8/2021 4:46:36 PM
(None)
Signature Adoption: Drawn on Device
Using IP Address: 174.49.130.108
Electronic Record and Signature Disclosure:

Accepted: 12/8/2021 4:23:02 PM
ID: 1e8550b9-1dfd-402f-934d-e5ddb399d230
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps

Envelope Sent Hashed/Encrypted 12/8/2021 4:17:24 PM
Certified Delivered Security Checked 12/8/2021 4:23:02 PM
Signing Complete Security Checked 12/8/2021 4:46:36 PM
Completed Security Checked 12/8/2021 4:46:36 PM
Payment Events Status Timestamps

Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: 11/5/2021 5:16:44 PM
Parties agreed to: Haryadi Haryadi
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, Options Insurance (we, us or Company) may be required by law to provide to
you certain written notices or disclosures. Described below are the terms and conditions for
providing to you such notices and disclosures electronically through the DocuSign system.
Please read the information below carefully and thoroughly, and if you can access this
information electronically to your satisfaction and agree to this Electronic Record and Signature
Disclosure (ERSD), please confirm your agreement by selecting the check-box next to ‘I agree to
use electronic records and signatures’ before clicking ‘CONTINUE’ within the DocuSign
system.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after the signing session and, if you
elect to create a DocuSign account, you may access the documents for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per-page fee. You may request delivery of such paper copies from us by following the
procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.
All notices and disclosures will be sent to you electronically

Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact Options Insurance:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: esignallentown@gmail.com
To advise Options Insurance of your new email address
To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us at esignallentown@gmail.com and
in the body of such request you must state: your previous email address, your new email
address. We do not require any other information from you to change your email address.
If you created a DocuSign account, you may update it with your new email address through your
account preferences.
To request paper copies from Options Insurance
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to esignallentown@gmail.com and in the
body of such request you must state your email address, full name, mailing address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with Options Insurance
To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your signing session, and on the subsequent page,
select the check-box indicating you wish to withdraw your consent, or you may;
ii. send us an email to esignallentown@gmail.com and in the body of such request you must state
your email, full name, mailing address, and telephone number. We do not need any other
information from you to withdraw consent.. The consequences of your withdrawing consent for
online documents will be that transactions may take a longer time to process..
Required hardware and software
The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: https://support.docusign.com/guides/signer-guide-
signing-system-requirements.
Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for
your future reference and access; or (ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before
clicking ‘CONTINUE’ within the DocuSign system.
By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm
that:
 You can access and read this Electronic Record and Signature Disclosure; and
 You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
 Until or unless you notify Options Insurance as described above, you consent to receive
exclusively through electronic means all notices, disclosures, authorizations,
acknowledgements, and other documents that are required to be provided or made
available to you by Options Insurance during the course of your relationship with Options
Insurance.

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DocuSign Envelope ID: FFB2CAA4-B533-451C-90F8-67E6013B385B

Underwritten by: Bristol West Insurance Company

DATE: 12/08/2021 TIME: 03:28 ET TRANSACTION: New Business

Proof of Prior Insurance:

MINIMUM PAGES INCLUDING THIS COVER: _# of docs + 1_

NAMED INSURED PRODUCER INFORMATION

DRIVER AND RESIDENT INFORMATION

AUTO INSURANCE HISTORY

App 001 (05/19)

Underwritten by: Bristol West Insurance Company

Vehicle 1: 2013 VOLKSWAGEN JETTA BASE S SD

Coverage Limit Per Person Limit Per Accident Deductible Premium

Total Premium for 2013 VOLKSWAGEN JETTA BASE S SD $433.00

TOTAL POLICY PREMIUM

App 001 (05/19)

Underwritten by: Bristol West Insurance Company

this application are garaged in Pennsylvania at least (10) months a year.

vehicle is principally garaged.

THIS PENNSYLVANIA POLICY.

App 001 (05/19)

Underwritten by: Bristol West Insurance Company

Signature of Named Insured Date

App 001 (05/19)

Underwritten by: Bristol West Insurance Company

Bodily Injury: $77.00

App 001 (05/19)

Date: 12/08/2021 Page 6

Underwritten by: Bristol West Insurance Company

App 001 (05/19)

Underwritten by: Bristol West Insurance Company

App 001 (05/19)

Underwritten by: Bristol West Insurance Company

<BW.PA1.N> <BW.PA1.DS> am/pm

Producer Signature Date Time

MICHAEL WILLIAM WOODFORD <BW.PA1.S>

Producer Name (Print) Producer License No.

App 001 (05/19)

Underwritten by: Bristol West Insurance Company

Pennsylvania Surcharge Disclosure Statement

SURCHDISC (07/20) Date: 12/08/2021 Page 10

Underwritten by: Bristol West Insurance Company

REJECTION OF UNDERINSURED MOTORIST PROTECTION

Signature of First Named Insured

Underwritten by: Bristol West Insurance Company

REJECTION OF UNINSURED MOTORIST PROTECTION

Signature of First Named Insured

Underwritten by: Bristol West Insurance Company

NOTICE OF TORT OPTIONS

Underwritten by: Bristol West Insurance Company

NOTICE TO NAMED INSUREDS

Additional coverages under this option are available at additional cost.

Additional coverages under this option are available at additional cost.

I wish to choose the "limited tort" option described in paragraph A:

Named Insured Date

I wish to choose the "full tort" option described in paragraph B:

Named Insured Date

Underwritten by: Bristol West Insurance Company

1. Medical Benefits, up to at least $100,000.

3. Accidental Death Benefits, up to at least $25,000.

4. Funeral Benefits, $2,500.

5. As an alternative to paragraphs 1, 2, 3, and 4, a combination benefit, up to at least $177,500 of benefits

Signature of First Named Insured Date