1/19/24, 3:05 PM Auto Application

Illinois Auto Programs AUTOMOBILE APPLICATION

PO BOX 389508 Producer Name RIGHT PRICE INS & SRVS INC
CHICAGO, IL 60638-9508 Address 5251 N HARLEM AVE STE B
888-262-8864 City, State, ZIP CHICAGO, IL 60656
X Symbol Rated
Phone Number (773) 886-1800
Value Rated Producer Code 4512686

POLICY INFORMATION PRIOR INSURANCE INFORMATION

Effective Date 01/19/24 Time 02:05 PM Company NO PRIOR
Expiration Date 07/19/24 Time 12:01 AM Expiration Date
Policy Term 6 Policy Number ILS 934318-00 Policy Number
Coverage is bound no earlier than 02:05PM the date received by Company (premium or deposit must be enclosed) unless prior arrangements are made with Company.
APPLICANT INFORMATION AUTO/GARAGE INFORMATION (If different from mailing address)
Named Insured ZORIANA VERESIUK Address:
Mailing Address 7733 LECLAIRE AVE City, State, ZIP:
City, State, ZIP BURBANK, IL 60459-1541 CONTENTS PLUS RENTERS ENDORSEMENT INFORMATION
Home Phone (773) 415-5733 (If information is different from mailing address)
Work Phone | Cell Phone Address:
Email Address [email protected] City, State, ZIP:
DRIVER(S) The Applicant warrants that: 1) All drivers in the household over the age of 15 have been listed on this application
and 2) All possible drivers even those that may operate the Applicant's vehicle(s) on an irregular or infrequent basis have
been listed on this application. The Applicant understands that failure to list all drivers and household members is a material Initials ZV
misrepresentation of the policy contract.
Marital/Civil SR
Name DOB Sex Union Status Relation License # ST Points 22
ZORIANA VERESIUK 09/13/01 F S INSURED V62298001861 IL 0 N
EMPLOYMENT
Name Employer Street City ST ZIP Occupation
ZORIANA VERESIUK SELF EMPLOYED BURBANK IL SELF EMPLOYED
VIOLATIONS / LOSSES / CONVICTIONS / SUSPENSIONS / REVOCATIONS
Drv # Date Description Drv # Date Description
01.19.2024
VEHICLE(S) (OWNED OR LEASED)
Comp Coll Anti
Yr. Make/Model/Style VIN Sym Sym Sym Theft Usage ACV Ter Class
2003 BMW / 330CI / CONVERT WBABS53423JU99507 22 22 22 Y Basic 8405 37344 22SF
LIEN-HOLDER(S)/ADDITIONAL INTEREST
Vehicle/Property Name Street City ST ZIP

COVERAGES LIMITS OF LIABILITY Veh 1 DISCOUNTS

Bodily Injury Liability $ 25,000 per person / $ 50,000 $ 161 Liability Only Discount,Paid In Full
per accident Discount
Property Damage Liability $ 25,000 per accident $ 232
Uninsured Motorists - BI $ 25,000 per person / $ 50,000 $ 60
per accident
Underinsured Motorists - BI $ 25,000 per person / $ 50,000 INCL.
per accident
Uninsured Motorists - PD $ 15,000 per accident - $250 $ 33
Ded
Medical Payments (Excess) $ 5,000 per person $ 30
VEHICLE TOTALS $ 516
All Fees $ 0.00 PAYMENT METHOD
Total Premium $ 516.00 Direct Bill:
Paid In Full

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PA017-B Ed. 09-23

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Name Insured: ZORIANA VERESIUK Policy Number: ILS 934318-00

Underwriting Questions
Explain all "Yes" responses in remarks section

1.) Does the Applicant, any scheduled drivers, and/or insured vehicles travel and/or reside outside the policy YES NO X
state more than one month per year?
2.) Are any driver(s) not properly licensed? (If "Yes" explain) YES NO X

3.) Have any possible drivers, even those that may operate your vehicle on an irregular or infrequent basis, NOT YES NO X
been listed on this application or In the Remarks section?
4.) Has any driver been convicted of a motor vehicle felony, manslaughter or reckless homicide, or had license YES NO X
cancelled, suspended or revoked? (If "Yes" explain)
5.) Is any household resident over the age of 15 not listed on this application or in the Remarks section? (This YES NO X
also includes youthful operators who are resident students at school.)
6.) Has any married insured not listed their spouse on the drivers section of the policy or excluded the spouse YES NO X
with a signed endorsement? (If "Yes" explain)
7.) Is any vehicle used for business? (If "Yes", please explain and list all employees.) YES NO X

8.) Does any vehicle have any existing physical damage, including glass breakage? (If "Yes" explain) YES NO X

9.) Are any vehicles located at an address different from the garaging address listed on the application? (If "Yes" YES NO X
explain)
10.) Does any vehicle have special equipment i.e. special paint, sound system or other customizations? (If "Yes" YES NO X
explain)
11.) Do you own any other vehicles not listed on this application? (If "Yes" explain) YES NO X

12.) Is any vehicle not solely titled to Applicant's name? Any co-owner and/or co-signer must be disclosed. (If "Yes" YES NO X
explain)
13.) Have any accidents or moving violations for any drivers, including those involving a parked car or hit and run, YES NO X
in the past 3 years NOT been listed on the application?
14.) Does any driver have, or in the past 3 years, has any driver been treated for a physical or mental condition YES NO X
that might affect the driver's ability to safely operate a motor vehicle? If "Yes", submit a complete Medical
Authorization/Physicians report. We do not discriminate against qualified drivers with disabilities.
15.) Has any vehicle been modified? (If "Yes" explain) YES NO X

16.) Is any vehicle used as a public or livery conveyance, including any use of the vehicle in conjunction with any YES NO X
transportation network applications or companies (TNC) or as they are sometimes also known as rideshare
applications or companies, pertaining exclusively to the transportation of individuals for a fee? (If "Yes", list the
average verifiable hours worked per week over the past 90 days.)
( ) 18 hours or less ( ) More than 18 hours
16a.) If "Yes" are you also applying for the TNC Endorsement? (If "Yes", list the vehicle(s)) YES NO X

17.) Is any vehicle used as a public or livery conveyance pertaining to any forms of livery including but not limited YES NO X
to products, documents, newspapers, or food? (If "Yes", list the average verifiable hours worked per week
over the past 90 days.)
( ) 18 hours or less ( ) More than 18 hours
17a.) If "Yes", are you also applying for the Individual Delivery Coverage Endorsement? (If "Yes", list the vehicle(s)) YES NO X

18.) Are you also applying for Contents PLUS Renters Endorsement? YES NO X

18a.) If applying for Contents PLUS Renters Endorsement, have there been any losses in the past 3 years YES NO X
(regardless of any applicable insurance coverage)? (If "Yes" explain listing lost date, loss cause and amount)
18b.) If applying for Contents PLUS Renters endorsement, have you been charged with or convicted of the crime of YES NO X
arson in the last 5 years?

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19.) Does any vehicle have a salvage history including rebuilt or flood designation? (If "Yes", list the vehicle(s)) YES NO X

REMARKS

I/We warrant that I/We have read and understand all of the questions asked, and have answered them truthfully to the best of PA017-B
my ability. Ed. 09-23
I/We understand that any misleading or false answers to these questions could jeopardize the coverage afforded in this policy.

Applicant's Signature X Date: 01/19/2024

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This section applies only when the Bodily Injury Liability exceeds the basic statutory limits.
Additional Uninsured Motorist/Underinsured Motorist Coverage must be purchased in the same amounts as bodily injury limits of coverage if
bodily injury coverage is sought in amounts greater than $25,000/$50,000 unless the Applicant rejects additional uninsured motorist coverage in
writing on a company form which must be signed by the Applicant and submitted with this application.
x I/We reject Uninsured Motorist/Underinsured Motorist Coverage in limits exceeding the minimum statutory requirements.
I/We request increased Uninsured Motorist/Underinsured Motorist Coverage limits as indicated on this application.

Applicant Initials: ZV

Uninsured Motorist Insurance Property Damage (UMPD): Pays the lesser amount of the actual cash value of the covered motor vehicle or up to
the corresponding policy limit subject to a $250 deductible, against damages from actual contact with a confirmed uninsured motorist or
vehicle(s) owner. The offer of this coverage is required by law.

I/We reject Uninsured Motorist Insurance Property Damage (UMPD) on the following vehicle(s)
Vehicle 1
x I/We request Uninsured Motorist Insurance Property Damage (UMPD) on the following vehicle(s)
x Vehicle 1

Applicant Initials: ZV

I understand that the coverage selection and limit choices indicated here will apply to all future policy renewals, continuations and changes
unless I notify the Company otherwise in writing.

Statement of No Commercial Use

I/We hereby certify that the vehicle(s) listed on this application for insurance are not used for any commercial or business purposes unless
properly identified on the application and rated with appropriate surcharge on the Declarations page. I/We will not use my vehicle(s) in the
course of my employment or while I/We am self-employed. Business use includes the use of those operators who visit multiple work sites during
one day, do not travel to the same site each date or those whose occupations require working at more than one (1) job site for a period of time
and then working at a different site for another period of time. Said usage includes, but is not limited to, operation of a vehicle while it is being
used as a public or livery conveyance, including any use of the vehicle, whether or not passengers are present in the vehicle, in conjunction
with any transportation network applications or companies, or as they sometimes refer to themselves, rideshare applications or companies.
Examples of these include, but are not limited to, Uber and Lyft. Usage also includes operation of any vehicle to transport individuals, packages,
mailings, deliveries, products, envelopes, food, or other tangible items. A Home Health Care worker traveling to more than two (2) patient's
homes per day must be rated for business. I/We understand that use of said vehicles for any commercial or business purposes could be a
violation of the terms and conditions of this policy and jeopardize my coverage.

Applicant's Signature X Date 01/19/2024

Applicant Statement
The Applicant warrants that he/she has read the Application, and that all answers herein are true and correct and that First Chicago Insurance
Company ("Company") may rely on the information provided herein to issue an insurance policy. The Applicant acknowledges that this
Application forms a part of the insurance policy so issued and that if any representation contained in this Application is false, misleading or
materially affects the acceptance or rating of this risk by the Company, by direct misrepresentation, omission, concealment of material fact or
incorrect statement, then the Company may rescind the policy. If the insurance policy is rescinded by the Company, there shall be NO
COVERAGE under this policy for any loss, accident or claim occurring at any time during the term stated in the declarations. Additionally,
without rescinding the policy, the Company shall not provide any coverage under the policy for a claim concerning which the insured or claimant
has made a fraudulent statement or engaged in fraudulent conduct in connection with an accident or loss for which coverage is sought under
the insurance policy. The Applicant further acknowledges that NO COVERAGE will be effective if the down payment for the insurance policy
issued from this Application is not honored for any reason. The Applicant warrants there are no other residents of insured's household (aged 15
and older) and no regular drivers other than those listed on this application. The Applicant agrees to notify the Company within 14 days of: 1) a
newly licensed member of his/her household or any new resident of his/her household aged 15 years or older, and 2) change of address and/or
any garaging changes. The Applicant also agrees to notify the Company immediately upon his/her license, or that of any regular driver, being no
longer valid.

I/We hereby apply to the company for a policy of insurance as set forth in this application on the basis of statements contained herein. I agree if
such information is false, or misleading or would materially affect acceptance of the risk by Company, or if my check is returned to the Company
for insufficient funds, or if my premium remittance is not honored by the bank, that such policy will be null and void and no coverage shall be

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afforded. I understand a routine inquiry may be made which will provide applicable information concerning character, general reputation,
personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made,
will be provided. I hereby authorize the company to obtain from the state a copy of Motor Vehicle Reports for use in rating and/or underwriting
the insurance for which I do hereby apply, and any renewal thereof, I certify that I am authorized to permit the company to obtain Motor Vehicle
Reports on all drivers listed herein.

Should a Motor Vehicle Report disagree with the information furnished on this application, or if other rating discrepancies be determined, I
hereby consent to pay any resulting additional premium.

Applicant's Signature X Date 01/19/2024

PA017-B Ed. 09-23

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The undersigned hereby warrants and certifies that to the best of his/her knowledge all information contained herein is correct; the statements
herein are those of the Applicant who has signed this application in my presence, and that the Applicant and the undersigned are retaining a
duplicate signed copy hereof. I am legally qualified to submit this application on behalf of the Applicant.

Producer's Signature X Date/Time 01/19/2024 /

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PA017-B Ed. 09-23

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