ONLINE ACCESS AIG - AUTO INSURANCE BINDING REQUEST

Congratulations! All you need to do now is complete your application, and make your payment. We will e-mail you Your Insurance Card! . All applicable questions must be answered, please write n/a when a question is not applicable.   General Information . Email Address: First/Last Name Of Primary Driver: Fax Number Payment Plan Type: _ One Pay D-2 D-3 D-5 D-F D-G D-H D-K D-Q T/M (EFT) W-M (EFT) If "Payment Plan Type" is "(EFT)" you MUST complete the Bank Information. Name of Bank to be use for payments: Bank Street Address: Bank City, State & Zip: Account Number: Routing Number (9 digits): . Payment Amount: Effective Date Desired: mm December January dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 2000 2001 .   Additional Info. For Drivers 1-2 .     Driver 1 (Main) Driver 2 Drivers License #   License State:   _ AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA ME MD MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY _ AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA ME MD MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Date of Birth:   Years Licensed:   DL Currently Revoked?   yes no yes no DL Suspend. on Last 5Yrs:   yes no yes no Time Length at Current Address:   Social Security #   Owner of Vehicle:   Vehicle 1 Vehicle 2 Vehicles 1-2 None Vehicle 1 Vehicle 2 Vehicles 1-2 None Employer's name:   Occupation:   Work Phone:   Years/Month With Employer:   .   Excluded Drivers . All persons over the age of 14 living with you and not rated in this policy What is the number of excluded drivers _ 01 02 03 04 05 NONE . . .     Excluded Driver 1 Excluded Driver 2 First Name:   Last Name:   Date of Birth:   Relation To Insured:   Spouse Relative Child Grandprts. Not Related Spouse Relative Child Grandprts. Not Related Reason To Be Excluded:   _ Turned DL to Dept. Never Licensed Other Insurance _ Turned DL to Dept. Never Licensed Other Insurance If Other Insurance Comp. Name:   Policy Number:   .   Additional Info. For Vehicles 1-2 .     Vehicle 1 Vehicle 2 VIN #:     yes no yes no If Loss Payee - Name:   If Loss Payee - Address/PB:     yes no yes no If Additional Interest - Name:   If Add. Interest - Address/PB:   .   Application Information . 1. Is any Vehicle titled or registered to anyone other than the applicant or spouse: yes no If yes Name : and Address: 2. Has anyone in household or any other regular operator ever been charge with a felony that resulted in a conviction, a guilty or nolo contendere plea, or veridict, a plea to a lesser charge, or have any similar cases pending? yes no 3. Does anyone in household or any operator have a physical or mental impairment: yes no if yes describe,(include driver name): 4. Does any operator take continuing medication that may impair driving ability: yes no if yes describe(include driver name): 5. Does the vehicle have existing damage or glass breakage: yes no if yes describe: 6. Is the vehicle use in business? Deliveries? (such as pizza, newspagers, etc...) yes no if yes explain, and # of trips per day: 7. Has the name insured/spouse been in a bankruptcy status, subject to tax lien or sustained 3 or more judgements within last 7 years yes no if yes describe: 8. Does the vehicle have special equipment, or non-factory equipment, accessories or options? (optional or add-on equipment/accessories not specifically declosed with a premium charge, will not be covered under this policy) yes no if yes describe: If insured for the past 6 months you MUST complete the following Information. Name of Insurance Company: Policy Number: Effective Date: Expiration Date: .   Questions / Comments .

customer service: 954.927.0255