California insurance binder

CALIFORNIA INSURANCE POLICY

Combo Program

State National Dealer Program
Producer Name and Address: Wallis and Wallis Insurance Brokers 1249 Park Avenue San Jose, CA 95126	Producer Phone: [phone] Producer Fax: [phone] DATE OF APPLICATION:
Driver Information

Name:
Address:
Phone:			Cell:
DOB:	DL#:	State Issued:	Date First Licensed:	Sex:	Marital Status:
Additional Driver Number Two		Name:
DOB:	DL#:	State Issued:	Date First Licensed:	Sex:	Marital Status:
Additional Driver Number Three		Name:
DOB:	DL#:	State Issued:	Date First Licensed:	Sex:	Marital Status:

Applicant’s Signature _____________________________________

Vehicle Information

Year:	Make:	Model:	VIN:
Lien Holder Name:		Address:

Dealership Information

Name:

Phone Number (Area Code First)

BASE LIMITS COMBO PROGRAM

PREMIUM AND FEES

$15,000/$30,000 Bodily Injury (BI)	$410.00	ZONE A (Oakland, Sacramento, San Bernardino,
$10,000 Property Damage (PD)	San Diego, San Francisco, Stockton, Los Angeles)
$1000 Medical Payments (MP)
$15,000/$30,000 Uninsured Motorist (UMBI)	$345.00	ZONE B (Remainder of State)
Property Damage Waiver Comprehensive/Collision
Deductible $500, Towing $50/$100 Maximum	PLEASE CIRCLE AND PAY PREMIUM REQUIRED
Rental $30 Day/$450 Maximum

Applicant’s Signature ______________________________________
This insurance form is used only by the authorized holder of a valid automobile dealer’s insurance master policy. Coverage is effective only if bound by fax and the applicable 30 day premium and fees are paid. The application must be filled out, signed and faxed to 408-293-6054 or 408-364-1279. To the insured, by signing this application, I hereby appoint Wallis and Wallis Insurance Brokers, License Number 0711895, as my/our attorney in fact, to sign papers, applications, cancellation documents and finance agreements that may be necessary in order to secure insurance coverage at my request. Note: an attorney cannot make an affidavit or certification of the truth of facts unknown to him. All premiums and fees all fully earned when policy is issued. All drivers must be listed for coverage to be afforded under this policy.

Applicant’s Signature _____________________________________ Date _______________

Date Faxed _______________ Time Faxed _________ am ( ) pm ( )

FAX TO [phone] OR [phone] FOR IMMEDIATE BINDING

Important Information Regarding Your Automobile Insurance
This document evidences coverage under a Certificate of Insurance issued pursuant to the Master Policy listed above. We will mail a copy of the Certificate to the address provided to us, as shown above within three (3) to five (5) business days after commencement of the coverage period shown above. There is no coverage provided for additional or replacement vehicles. Coverage terminates when the company mails you the required termination notice. The cost listed above is fully earned and non-refundable. The cost also includes a one hundred and forty dollar ($140.00) Broker Fee paid to Wallis and Wallis Insurance Brokers, for broker services provided to the Master Policyholder as outlined in the Description of Broker Fee Agreement listed below.
You consent to the dealer securing the above listed coverage and to the Dealer/Lender/Lessor, at its sole discretion, paying the cost for such coverage purchased in conjunction with your Motor Vehicle Contract and Security or Lease Agreement. You authorize the Dealer/Lender/Lessor to transmit information about you and the vehicle listed above to Wallis and Wallis Insurance Services for the purposes of offering you continuation coverage.
STANDARD BROKER FEE DISCLOSURE
Do not sign any broker fee agreement unless all of its blank lines and spaces have been filled in and you have read this entire document and the agreement carefully.

1. 
   Your insurance broker represents you, the consumer, and is entitled to charge a broker fee if he/she chooses. This fee is not set by law, and may be negotiable between you and the broker.
   
2. 
   It is illegal or improper for an insurance broker to charge you a fee for placing coverage solely with the California Automobile Assigned Risk Plan or the California FAIR Plan. Fees may be charged for placement of other coverage.
   
3. 
   Broker fees are often non-refundable even if you cancel your coverage. Refer to your broker fee agreement to see if your broker fee is non-refundable. However, you may be entitled to a full refund of a broker fee if your broker acted incompetently or dishonestly. Unresolved disputes over non-refunded broker fees can be forwarded to the Department of Insurance for review
   
4. 
   You are entitled to obtain and keep a completed copy of this disclosure and any broker fee agreement you sign.
   
5. 
   Your broker may receive commission from insurance company(ies) for placing your insurance. This commission may be paid to your broker by the insurance company(ies) in addition to any broker fee you pay.
   
6. 
   If you will be paying your premium in installments to a finance company, by law you must receive a copy of a premium finance disclosure and agreement. Be sure to obtain and read those documents before signing a premium finance agreement. Also, ask the broker if the insurer offers its own installment payment plan. Insurer installment plans are often cheaper than premium financing through a separate premium finance company.
   
7. 
   If your broker is placing automobile coverage, your broker must provide you with a copy of the current Department of Insurance pamphlet Automobile Insurance. If your broker is placing residential coverage, your broker must provide you with a copy of the current Department of Insurance pamphlet Residential Insurance. By signing this disclosure you acknowledge that this pamphlet will be mailed to you with the policy materials outlined in the Terms of Coverage and Disclosure of Fees.
   

DESCRIPTION OF BROKER FEE AGREEMENT

The Master Policyholder has agreed that, in addition to ordering the temporary insurance coverage under its Master Policy, he or she will pay Wallis and Wallis Insurance Services, California Department of Insurance License Number 0711895, a one hundred and forty dollar ($140.00) Broker Fee, which is fully earned and non-refundable, and acknowledge that the Master Policyholder has appointed Wallis and Wallis Insurance Services as its Broker of Record. If you reimburse Master Policyholder for the cost listed, you agree that reimbursement includes this one hundred and forty dollar ($140.00) broker fee. The Broker Fee Agreement is operative on the effective day of coverage and shall continue in force until terminated by the Master Policyholder or the broker. Wallis and Wallis Insurance Services agrees to represent the Master Policyholder honestly and competently. You acknowledge that you have read and received the Standard Broker Fee Disclosure issued to the Master Policyholder and provided above. In the case of any questions or problems concerning broker fees or insurance, contact the California Department of Insurance at 1-[phone].


Applicant’s Signature _____________________________________ Date _______________

Insurance Coverage Notice
An initial deposit has been made and you will be receiving a policy shortly. You will be contacted with an offer to continue coverage, as well as on offer to shop your insurance rates.
Please contact Wallis and Wallis Insurance Brokers in 20 days at [phone] if you have not been contacted by an agent or if you have any questions at all about your policy.


Aviso de la Cobertura de Seguro
Un depósito inicial ha sido hecho y recibiras una póliza pronto. Te llamarán con una oferta para continuar cobertura, o un oferta para buscar otro seguranza.
Por favor llame a Wallis and Wallis en 20 días a

[phone] si un agente no te llamado o si tienes cualesquiera preguntas sobre tu póliza.