Form_SCTNID_CTGRY.

IA07177982_APPLICAT

927936088 $ 31786 INS APPLICAT POLWHITEFONT UJ7ZYHVI3DMVUUC3VQEPAM4W5H0003 RPUID TRACWHITEFONT

Application for Insurance

Please review, sign where Policy Number: 927936088
indicated and return Policyholder:
Brittney Miller
March 5, 2019
Page 1 of 5
Policy and premium information for policy number 927936088
………………………………………………………………………………………………………………………………………………………..
Insurance company: Progressive Northern Insurance Co
PO Box 6807
Cleveland, OH 44101
………………………………………………………………………………………………………………………………………………………..
Agent: GREGORY V GISI
AMERICAN FAMILY BRKR
6000 AMERICAN PKWY
MADISON, WI 53783
31786
1-800-692-6326
………………………………………………………………………………………………………………………………………………………..
Named insured: Brittney Miller
204 Brantingham St
Charles City, IA 50616
e-mail address: none
Home:
Work: 1-641-426-6835
Membership number: 23063
………………………………………………………………………………………………………………………………………………………..
Financial responsibility vendor: EXPERIAN
1-888-397-3742
………………………………………………………………………………………………………………………………………………………..
Policy period: Mar 5, 2019 - Sep 5, 2019
………………………………………………………………………………………………………………………………………………………..
Effective date and time: Mar 5, 2019 at 12:28PM ET
………………………………………………………………………………………………………………………………………………………..
Total policy premium: $1,221.00
………………………………………………………………………………………………………………………………………………………..
Initial payment required: $305.25
………………………………………………………………………………………………………………………………………………………..
Initial payment received: $305.25
………………………………………………………………………………………………………………………………………………………..
Payment plan: 6 payments

Drivers and resident relatives

The applicant, spouse and all resident relatives 14 years of age or older, all regular drivers of the vehicles described in this
application, and all children who live away from home who drive these vehicles, even occasionally, are listed below. Your
total policy premium can be affected by all persons of driving age. While designating drivers as List Only or Excluded may
increase policy premium, the violation and accident history of Excluded and List Only drivers does not affect premium.
Name Date of birth Sex Marital status Relationship
………………………………………………………………………………………………………………………………………………………..
Brittney Miller Aug 31, 1992 Female Single Insured
Driver status: Rated
Education level: High school diploma or GED
Occupation: Unemployed
Total residents: 1
The total number of residents currently residing in your household, including listed drivers, young children, roommates or
anyone else living in the home for 60 days or more during the next 12 months.

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927936088 $ 31786 INS APPLICAT POLWHITEFONT UJ7ZYHVI3DMVUUC3VQEPAM4W5H0003 RPUID TRACWHITEFONT

Policy Number: 927936088

Brittney Miller
Page 2 of 5
Outline of coverage
2003 FORD EXPLORER 4 DOOR WAGON
VIN: 1FMZU73W43UC66067
Garaging ZIP Code: 50616
Primary use of the vehicle: Commute
Length of vehicle ownership when policy started or vehicle added: Less than 1 month
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $705
Bodily Injury Liability $100,000 each person/$300,000 each accident
Property Damage Liability $50,000 each accident
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist $25,000 each person/$50,000 each accident 7
………………………………………………………………………………………………………………………………………………………..
Underinsured Motorist $25,000 each person/$50,000 each accident
………………………………………………………………………………………………………………………………………………………..
23
Medical Payments $1,000 each person 34
………………………………………………………………………………………………………………………………………………………..
Comprehensive Actual Cash Value
………………………………………………………………………………………………………………………………………………………..
$1,000 206
Collision Actual Cash Value $1,000 229
………………………………………………………………………………………………………………………………………………………..
Roadside Assistance 17
………………………………………………………………………………………………………………………………………………………..
Total 6 month policy premium $1,221.00

Driving history
Please review the following information carefully because driving history is used to determine your premium. All accidents
are considered at-fault and over any applicable payment threshold unless we receive additional information from you or
another source that proves otherwise. We obtain driving and claims history from one or more of the following sources:
• Your application (APP) • Motor Vehicle Reports and/or court data (MVR) - provided by
a consumer reporting agency
• Progressive claims history (PROG) • Comprehensive Loss Underwriting Exchange (CLUE) - provided by
a consumer reporting agency
Driver and Description Date Source/Consumer reporting agency
………………………………………………………………………………………………………………………………………………………..
Brittney Miller
at fault accident Jul 4, 2016 CLUE/LexisNexis
………………………………………………………………………………………………………………………………………………………..
Brittney Miller
driving without insurance on vehicle Mar 16, 2018 MVR/LexisNexis
The company may consider claims history of the insured in determining whether to decline, cancel, nonrenew, or
surcharge this policy. Any claim made under this policy will be reported to an insurance support organization.

Underwriting information
………………………………………………………………………………………………………………………………………………………..
Prior insurance: No

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927936088 $ 31786 INS APPLICAT POLWHITEFONT UJ7ZYHVI3DMVUUC3VQEPAM4W5H0003 RPUID TRACWHITEFONT

Policy Number: 927936088

Brittney Miller
Page 3 of 5

Notice regarding Uninsured/Underinsured Motorist Coverage

Uninsured/Underinsured Motorist Coverage does not cover damage done to your vehicle. It provides benefits only for
bodily injury caused by an uninsured or underinsured motorist. If you wish to be insured for damage done to your
vehicle, you must have collision coverage. Please check your policy to make sure you have the coverage desired.

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927936088 $ 31786 INS APPLICAT POLWHITEFONT UJ7ZYHVI3DMVUUC3VQEPAM4W5H0003 RPUID TRACWHITEFONT

Policy Number: 927936088

Brittney Miller
Page 4 of 5
Application agreement
Verification of content
I declare that the statements contained herein are true to the best of my knowledge and belief and do agree to pay any
surcharges applicable under the Company rules which are necessitated by inaccurate statements. I declare that no persons
other than those listed in this application regularly operate the vehicle(s) described in this application. I declare that none
of the vehicles listed in this application will be used to carry persons or property for compensation or a fee, or for retail or
wholesale delivery, including, but not limited to, the pickup, transport, or delivery of magazines, newspapers, mail, or
food, except for rideshare use of any such vehicle for which Progressive Rideshare Insurance has been purchased. I
understand that this policy may be rescinded and declared void if this application contains any false information or if any
information that would alter the Company's exposure is omitted or misrepresented.
Notice of information practices
I understand that to calculate an accurate price for my insurance, the Company may obtain information from third parties,
such as consumer reporting agencies that provide driving, claims and credit histories. The Company may use a
credit-based insurance score based on the information contained in the credit history. The Company or its affiliates may
obtain new or updated information to calculate my renewal premium or service my insurance. I may access information
about me and correct it if inaccurate. In some cases, the law permits the Company to disclose the information it collects
without authorization. However, the Company will not share personal information with nonaffiliated companies for their
marketing purposes without consent. Complete details are in the Company’s Privacy Policy, which will be provided with
this insurance policy and upon request.

Acknowledgement and agreement

• If I make my initial payment by electronic funds transfer, check, draft, or other remittance, the coverage
afforded under this policy is conditioned on payment to the Company by the financial institution. If the
transfer, check, draft, or other remittance is not honored by the financial institution, the Company shall be
deemed not to have accepted the payment and this policy shall be void.
• If I make my initial payment by credit card, the coverage afforded under this policy is conditioned on payment
to the Company by the card issuer. I understand that if the Company is unable to collect my initial payment
from the card issuer, the Company shall be deemed not to have accepted the payment and this policy shall be
void. I also understand that if I authorize a credit card transaction for any payment other than the initial
payment, this policy will be subject to cancellation for nonpayment of premium if the Company is unable to
collect payment from the card issuer. The Company is deemed "unable to collect" in the following instances:
(1) when I reach my credit limit on my credit card and the card issuer refuses the charge; (2) when the card
issuer cancels or revokes my credit card; or (3) when the card issuer does not pay the Company, for any reason
whatsoever, upon the Company's request.
• This insurance and personalized service is available at this price exclusively through this Progressive independent
agent. Other Progressive independent agents and affiliated companies selling insurance directly may have different
prices or products. The SnapshotH Program is not available from all agents.
• The Company may obtain information, including vehicle history information, from third parties. I understand
that this information may affect my policy premium or could result in a policy declination, cancellation, or
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I understand that if I cancel this policy or if cancellation is due to non-payment of premium, any refund due will be
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computed on a ninety percent (90%) of daily pro rata basis. This is a daily, accelerated method of calculating short-rate
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earned premium on cancellations. When I renew this policy, I understand that the Company will refund premium
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following a cancellation on a daily pro rata basis.

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I agree to pay the installment fees shown on my billing statement that become due during the policy term and each
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renewal policy term in accordance with the payment plan I have selected. I understand that the amount of these fees
may change upon policy renewal or if I change my payment plan. Any change in the amount of installment fees will be
reflected on my payment schedule.

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927936088 $ 31786 INS APPLICAT POLWHITEFONT UJ7ZYHVI3DMVUUC3VQEPAM4W5H0003 RPUID TRACWHITEFONT

Policy Number: 927936088

Brittney Miller
Page 5 of 5
I understand that a returned payment fee of $20.00 will be assessed to the balance due on my policy if any check offered
in payment is not honored by my bank or other financial institution. Imposition of such charge shall not deem the
Company to have accepted the check unconditionally.
I agree to pay a late fee of $10.00 when the payment for the minimum amount due is not received or postmarked by the
premium due date. The amount of this fee may change upon policy renewal.

Signature of named insured Date

X ………………………………………………………………………………………………………………………………………………………..

Form 7982 IA (07/17)

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