please fax all information to (912) 236-8397. thank you for your...

Chappell Insurance Services, Inc.

Policy Number: Dear Agent, Thank you for uploading to CIS! Your customer’s policy has been rated and issued with a discount or an excluded driver. In order for the discount to apply, acceptable proof must be faxed to CIS within ten (10) business days. If acceptable proof is not received, the discount(s) will be removed effective policy inception date and the customer will be responsible for any additional premium due. Please provide acceptable proof for the following discounts:

� Transfer Discount: A Transfer Discount will apply if the named insured shows proof of prior coverage that verifies at least six (6) months continuous coverage with NO lapse between the prior policy’s expiration and the effective date of the CIS policy and is claim free. Acceptable proof includes the prior policy’s Dec page, a current renewal offer, or any other document that shows both the effective date and the expiration or cancellation date.

� Good Student Discount: Must be a full time student (single and under 25 years old). Acceptable proof is a certified statement from the school indicating that the student has met one of the following requirements during the preceding school semester—1) is in the upper 20% of his/her class scholastically; 2) maintains a “B” average or its equivalent; 3) maintains at least a 3.0 on a 4 point system; 4) is included in a “Dean’s List”, “Honor Roll”, or comparable list indicating scholastic achievement.

The discount will not apply if the driver in the 3 years preceding the policy period had: 1. Been involved in an at fault accident 2. Been convicted of any serious traffic offense, any traffic offense for

which 3 or more points may be assessed, any offense relating to drugs, or any felony charge.

3. Had a drivers license suspended for refusal to submit to a chemical test and that suspension has not been reversed, if appealed.

� Defensive Driver Discount: Please refer to CIS Manual for acceptable proof.

� Your customer’s policy currently lists an excluded driver. In order to avoid cancellation, the signed and dated exclusion form must be faxed to CIS immediately after uploading the policy. This form has generated with the policy.

Please fax all information to (912) 236-8397.

Thank you for your business!

CAIC-GA-01 (01-2011) Page 1 of 4

A P P L I C A N T

Name First Middle Last

Mailing Address

City

County

State

Zip

Terr

Home Phone

Garaging Address (if different than Mailing address) City

County

State

Zip

Terr

Work Phone

P R O D

Producer Name

Producer Number

Address City

State

Zip

Producer Phone

L I M I T S

Liability BI/PD

25/50/25

D I S C O U N T S

Transfer 0 day lapse

Multi-Car

P O L I C Y

Term: 6 months with policy period:

From:

To:

Time: A.M. P.M.

Uninsured Motorist BI/PD

reduced UM Deductible NONE 25/50/25 added on 250 500 1000

Medical Payments

NONE Option I (Full Med) 1000 2000 Option II (Limited Med) 1000 2000

V E H I C L E

Year

Make

Model

Driver

VIN

Sym

Surcharge % or Level

1

2

3

4

C O V E R A G E S

V e h

Liab BI/PD Premium

Uninsured BI/PD

Premium

Med Pay Premium

Comp/Collision Comp. Collision Deductible Premium Premium

Rental Reimburse.

Towing & Labor

Repatriation (Named

Insured Only)

1

No 250 500 1000 Yes / No Yes / No

No 6000 10000 Beneficiary:

2 No 250 500 1000 Yes / No Yes / No

3 No 250 500 1000 Yes / No Yes / No

4 No 250 500 1000 Yes / No Yes / No

D R I V E R S

All residents of the household age 14 and over must be listed, including all unmarried children, wards, and foster children that are not emancipated, even if not a resident of the household. NO COVERAGE FOR UNLISTED DRIVERS. For each show name, date of birth, sex, and marital status even if not an operator. Any person whose license is suspended must be excluded.

Driver Name Driver’s License State Date of Birth MM/DD/YY

Social Security Sex M/S

Good Student

Def. Driver

SR-22

1 / /

Y / N Y / N Y / N

2 / /

Y / N Y / N Y / N

3 / /

Y / N Y / N Y / N

4 / /

Y / N Y / N Y / N

Check if any operator of the automobile has ever had: Epilepsy Stroke Diabetes Loss of Eye Cerebral Palsy Heart Attack Loss of Limb If any item is checked, a Physician’s Statement or Altered Vehicle Statement must be attached.

P O I N T S

Statement of all accidents and traffic violations during the past 36 months for all drivers:

A M T D U E

Paid in Full Pay Plan

Driver Name Date MM/DD/YY

Description Pts Total Premium = $ $

1 / /

Down payment x 1.00

2 / /

Subtotal =

3 / /

Policy Fee + $ $

4 / /

Other Fees (SR22) + $ $

5 / /

Amount Due = $ $

Chappell Insurance Services P.O. Box 8910 Savannah, GA 31412 (800) 280-0955

Underwritten by: Commercial Alliance Insurance Company 415 Lockhaven Dr Houston, TX 77073 (713) 960-1214 Georgia Private Passenger Auto Application

Has applicant been advised that failure to disclose all accidents and violations will jeopardize his coverage? Yes No Agency Check Insured Check Check Number:

CAIC-GA-01 (01-2011) Page 2 of 4

LIEN HOLDER

Vehicle Number

Name Address City State Zip Phone

Vehicle Number


Vehicle Number


UM SELECT / REJECT FORM

This is an important coverage. You must select or reject this coverage. Please read it carefully. Do not sign before reading. Your signature is required. If you have questions, please ask your agent. Your agent can explain this coverage to you if you have questions. You must choose one of the following Uninsured Motorists Coverage options. I select REDUCED Uninsured Motorists Coverage with limits shown on the application for insurance and therefore reject ADDED ON Uninsured Motorists Coverage. I further select my deductible for Uninsured Motorists Coverage to be 250 500 1000 I select ADDED ON Uninsured Motorists Coverage with limits shown on the application for insurance and therefore reject REDUCED Uninsured Motorists Coverage. I further select my deductible for Uninsured Motorists Coverage to be 250 500 1000 I reject Uninsured Motorists Coverage entirely. I understand that this rejection applies to my present auto insurance policy and to all future renewals or replacements of this policy. If I want to request Uninsured Motorists Coverage at some future time, I must let the Company or my agent know in writing. BY SIGNING BELOW, I CERTIFY THAT THE OPTIONS SHOWN IN THIS SECTION HAVE BEEN EXPLAINED AND OFFERED TO ME. I UNDERSTAND THAT THE UNINSURED MOTORISTS COVERAGE LIMIT MAY NOT EXCEED THE BODILY INJURY LIABILITY LIMIT CHOSEN IN THIS APPLICATION FOR INSURANCE. I HAVE SELECTED THE OPTION AND COVERAGES FOR MY AUTOMOBILE POLICY AS INDICATED ABOVE.

Signature of Applicant: Date:

MP SELECT / REJECT FORM

This is an important coverage. You must select or reject this coverage. Please read it carefully. Do not sign before reading. Your signature is required. If you have questions, please ask your agent. Your agent can explain this coverage to you if you have questions. The Medical Payment Coverage Options have been fully explained and offered to me. I understand that Option II has a reduced premium because that coverage does NOT include chiropractic services or services delivered under the direction of a chiropractor. I fully understand all the Medical Payment Options and do hereby for this policy and any renewal thereof select or reject as indicated below: You must choose one of the following Medical Payments Coverage options. I select Medical Payments Coverage Option I (Full MED) with limits shown on the application for insurance of 1000 2000 I select Medical Payments Coverage Option II (Limited MED) with limits shown on the application for insurance of 1000 2000 I reject Medical Payments Coverage entirely. I understand that this rejection applies to my present auto insurance policy and to all future renewals or replacements of this policy. If I want to request Medical Payments Coverage at some future time, I must let the Company or my agent know in writing.


INSPECTION

I have personally inspected the vehicle(s) described on this application and: The vehicle identification number(s) has been verified. Inspection Form and Photos have been enclosed for each vehicle(s). Inspection Form and Photo(s) have been submitted for any vehicle with existing damage.

Signature of Agent: Date:

CAIC-GA-01 (01-2011) Page 3 of 4

UNLISTED RESIDENT

DRIVER EXCLUSION

I understand and agree that I am required to list drivers and motor vehicles in the application. I understand and agree that all members and residents of the household age 14 and over are listed on the application. I understand and agree that failure to completely and accurately inform the company of all members and residents of the household age 14 and over may constitute fraud or misrepresentation. I understand and agree that the company will provide no coverage for any claim arising from an accident or loss incurred when a listed vehicle is operated by any unlisted member or resident of the household age 14 and over. However, if the family member or resident of your household is not entitled to recover damages under any other policy of insurance, then this exclusion shall only apply to the extent that the limits of liability for this coverage exceed the limits of liability required by the Georgia Motor Vehicle Safety Responsibility Act. I UNDERSTAND AND WARRANT TO COMMERCIAL ALLIANCE INSURANCE COMPANY THAT ALL DRIVERS IN MY HOUSEHOLD ARE LISTED ON PAGE ONE (ABOVE) OF THIS APPLICATION. IF ANY UNLISTED RESIDENT OF MY HOUSEHOLD OPERATES ONE OF THE VEHICLES INSURED UNDER THIS POLICY, SUCH USE WOULD BE STRICTLY WITHOUT MY EXPRESSED OR IMPLIED PERMISSION. Signature of Applicant: Date:

NAMED DRIVER

EXCLUSION

First Excluded Driver NAME

First Middle Last Date of Birth Relationship

Second Excluded Driver NAME

First Middle Last Date of Birth Relationship

All regular drivers, members or residents of the household age 14 and older must be rated for coverage or excluded from coverage. I agree with the company that no coverage for any claim arising from an accident or loss incurred when a covered auto or any other auto is operated, maintained, or used by a driver(s) specifically excluded from coverage at the time of application or by endorsement. This exclusion applies whether or not the use is with my permission. This includes any claim for damages made against me, or a family member or resident or any other person or organization for negligent entrustment, vicarious liability, or any other similar theory. This exclusion under this policy will apply to all renewals and changes thereof. Signature of Applicant: Date:

APPLICANT STATEMENT

I hereby apply to the Company for a policy of insurance as set forth in this application on the basis of the statements contained herein. The undersigned represent that the statements and answers recorded on this application are true and complete to the best of their knowledge and belief. I further certify all persons age 14 years or older who live with me are shown above. The undersigned agree that any policy issued from this application shall be null and void from inception if your down payment is returned unpaid for any reason. The company will not cover losses of any kind that occur after the inception of the policy if your down payment is returned unpaid. The undersigned agree that the company may void coverage under this policy if you or any insured have concealed or misrepresented any material fact or circumstance or engaged in fraudulent conduct, at the time application was made. We may void coverage under this policy or deny coverage for an accident or loss if you or any insured have concealed or misrepresented any material fact or circumstances, or engaged in fraudulent conduct, in connection with the presentation or settlement of a claim. We may void coverage under this policy for fraud or misrepresentation even after the occurrence of an accident or loss. This means that we will not be liable for any claims or damages that would otherwise be covered unless required by statute. I understand that Commercial Alliance Insurance Company (Company) may obtain consumer reports (which may include a driver history report, credit report or credit score) or personal or privileged information from third parties and I grant them the authority to do so. I must pay any additional premium due if there are chargeable traffic offense(s) not included on this application; otherwise coverage under this policy will be canceled. 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 resultant additional premium and agree to pay the late/lapse fee and the NSF fee, if applicable, before any premium will be applied. Upon request, additional information as to the nature and scope of the report, if one is made, will be provided. Applicants selecting the installment option are charged a non-refundable installment fee. Having had all of the optional coverages and optional limits offered and explained to me, I hereby sign for the acceptances or rejections for this policy and any renewal, replacement, reinstatement, transfer, or substitute thereof, and for any addition or substitution of any motor vehicle covered by such policy. Signature of Applicant: Date:

PRODUCER STATEMENT

I, the undersigned Producer, hereby certify that to the best of my knowledge, all information listed is correct. The statements listed are those of the applicant who has signed this form in my presence. The applicant and the undersigned are retaining a duplicate signed copy of this form. I am legally qualified to submit this form on behalf of the applicant. I have inspected the applicant’s vehicle(s) and found it free of all damage, except as noted on this application. Signature of Producer: Date:

Fraud Warning: Any person with intent to defraud or knowing that he is facilitating a fraud against an insurer, or submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud.

CAIC-GA-01 (01-2011) Page 4 of 4

SUMMARY OF COVERAGE LIMITATIONS

AND ACKNOWLED-GEMENT

This is a Summary of Coverage Limitations. This summary highlights some of the important limitations of your policy. You should review these coverage limitations carefully. Please read this carefully. Do not sign until you have read this completely. Your signature is required below. If you have questions, please ask your agent. Your agent can explain this to you if you have any questions. NO COVERAGE FOR PUNITIVE OR EXEMPLARY DAMAGES. Punitive or exemplary damages may be assessed in a lawsuit in order to punish the wrongdoer or to make an example of the wrongdoer. This policy will not afford coverage for you in the event that you, or an uninsured/underinsured motorist, become liable for punitive or exemplary damages. This also includes any fines, penalties or multiplied damages.

NO COVERAGE FOR UNLISTED DRIVERS. All residents of your household, including unmarried children, wards, and foster children that are not emancipated, even if they regularly live elsewhere, must be specifically included at the time of your application for insurance, and named on the Declarations Page to be covered. You may choose to exclude some or all residents from coverage. Your failure to identify and insure these persons and name them on the Declarations Page, or specifically exclude them from coverage, will result in a denial of coverage. Your failure to provide complete and accurate information in the application process may be deemed to be fraud or misrepresentation and may result in a denial of coverage. However, if the family member or resident of your household is not entitled to recover damages under any other policy of insurance, then this exclusion shall only apply to the extent that the limits of liability for this coverage exceed the limits of liability required by the Georgia Motor Vehicle Safety Responsibility Act.

NO COVERAGE FOR UNLISTED VEHICLES. There is no coverage under Part A (Liability) for your maintenance and use of a vehicle that is not listed on this policy which is owned by or regularly available for the use of you, a family member, or resident. This policy does not cover you while driving any car owned by or regularly available to a family member or resident of your home. If you wish to be covered on these additional vehicles, you must add them to this policy or purchase a separate policy.

NO COVERAGE FOR DAMAGE TO RENTAL/SUBSTITUTE VEHICLES. There is no coverage under this policy for damage to vehicles for which you or any insured person may rent, use, or have care, custody, and control. This policy does not afford coverage for damage you or another insured person may cause to any rental or substitute vehicle. If you borrow or rent a vehicle and wish to be covered for damage that you may cause to that vehicle, you must purchase additional coverage.

LICENSED PHYSICIANS ONLY. “Medical Services” has been defined in Part B (Medical Payments) to provide payment for those medical services provided by or under the supervision of a licensed physician. A “physician” is an individual licensed by a State or territory of the United States or District of Columbia to practice medicine, practice surgery, and prescribe drugs. In a claim under Medical Payments, this policy will only pay those expenses incurred for medical services which are defined in Part B (Medical Payments).

FOURTEEN (14) DAYS TO REPORT NEW OPERATOR(S) OR ADDITIONAL VEHICLE(S). If you or any listed driver acquires or becomes the principal user of any additional or replacement vehicle, and you want to cover that vehicle under this policy, you must tell us within 14 days of acquiring that vehicle.

NO COVERAGE FOR ANY BUSINESS USE. This policy does not cover the ownership or any operation of a vehicle while it is used for business purposes.

NO COVERAGE FOR CUSTOM PARTS OR EQUIPMENT. Coverage under Part D (Coverage for Damage to Your Auto) does not provide coverage for any furnishings, equipment, stereos, radios or other sound reproducing or video equipment, devices, accessories, enhancements, or changes that are not installed by the original manufacturer of the vehicle.

NO COMPREHENSIVE/COLLISION COVERAGE OVER $40,000. Coverage under Part D (Coverage for Damage to Your Auto) is limited to a maximum of $40,000, regardless of the actual cash value of the vehicle at the time of loss. If you have a vehicle that has an actual cash value over $40,000, you will not be covered under this policy for the amount that exceeds the maximum limits in the event of a loss.

YOU AUTHORIZE AND CONSENT TO ACCESS OF YOUR EDR. If your vehicle has an Event Data Recorder (EDR), or other similar device, your purchase of this policy and acknowledgement below is your consent and authorization to us to retrieve information collected and stored on that device in connection with any claim made under this policy.

IMPORTANT NOTICE AND CONSENT. You must notify us promptly if you move to another state or province. If your covered auto is no longer principally garaged in Georgia, or if you relocate and your covered auto is principally garaged outside of Georgia for more than 30 days, then your coverage will terminate.Your acceptance of this policy and your acknowledgement below serves as your notice to us of your consent and intent to terminate coverage when you or your covered auto is relocated outside of Georgia. By signing below you have given your consent and indicate your intent to terminate coverage under this policy effective the 31st day your covered auto is principally garaged outside of Georgia when you relocate to another state.

I hereby acknowledge that I have reviewed the Summary of Coverage Limitations and Acknowledgement. I accept this policy and its terms and conditions as the appropriate coverage option for me. My agent has explained this to me. Based on this explanation, these coverage options meet my auto insurance needs.


CAIC-GA-16 (01-2011) 1

COMMERCIAL ALLIANCE INSURANCE COMPANY _____________________________________________________________________________________________

Houston, Texas

(Herein Called the Company)

____________________________________________________________________________________________

YOU ARE COVERED FOR REPATRIATION FOR AUTO ACCIDENTAL DEATH ONLY. THIS ENDORSEMENT DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS.

READ YOUR ENDORSEMENT WITH CARE.

____________________________________________________________________________________________

TERMS AND CONDITIONS OF COVERAGE

_____________________________________________________________________________________________ Benefits specified below will be paid while the Endorsement is in force and the Covered Person suffers loss by

death, resulting directly from an accidental bodily injury (“such injury”) received as a result of an auto accident. The

accident itself, and/or the accidental injuries to the Covered Person, must have occurred within the U.S.A. The

accident must have occurred within the dates this Endorsement is in effect. If, within one (1) year from the date of

accident itself, the bodily injuries received in such accident results in death, the Company will pay the Endorsement

benefits. If a Covered Person lives for more than a year from the date he/she was originally injured, the death is not

considered accidental, per the terms and definitions of this Endorsement.

Loss means Repatriation Services from the United States of America to Mexico or Central America and/or

within the United States of America. The accidental death, from an auto accident, of the Covered Person

must have occurred in the U.S.A. for this Endorsement to provide benefits.

1. Repatriation of Body or Mortal Remains (Mexico or Central America)

In the event of the accidental death of a COVERED PERSON in the United States of America, COMPANY will coordinate the transportation of the body or mortal remains of COVERED PERSON to the designated place of burial or home town in Mexico or Central America. The COMPANY will request and pay the corresponding transfer permits. The payment of any related expenses will be covered by the COMPANY. All bodies will be embalmed if required by either the shipping or receiving country.

CAIC-GA-16 (01-2011) 2

2. Payment of Transactions and Negotiations In the event of accidental death caused by auto injury of a COVERED PERSON in the United States of America COMPANY will carry out, by available and reasonable means, the necessary transactions to transport and repatriate the body or mortal remains of COVERED PERSON to either the Republic of México and/or a designated location in the U.S.A. This service includes:

Certificate of Death (with original stamps and signatures). In the event of accidental death, notification affidavit to the authorities and if an investigation is pending or

in progress corresponding documentation. Necessary sanitary permits. Embalming and Embalming Certificate if required by health authorities and health regulations in the

country of origin or destination. Shipment casket. Apostilles and notarizations. Special packaging for transportation (if required by embassy). Payment of applicable duties and fees to complete transport.

3. Application Part of Endorsement

The insurer, Commercial Alliance Insurance Company, relies upon the information and representations contained in the Application, particularly as to the Beneficiaries whom will decide the place to ship the body/remains of the COVERED PERSON. II. Coordination of the Funerary Services in designated place or hometown.

1. If Mexico or Central America is the final and chosen designation to take the body/remains of the COVERED PERSON, the Company will provide:

a. Legal advice regarding accreditation of death to Authorities: The COMPANY, through

one of its network providers, will provide legal advice to surviving relatives regarding the necessary procedures or transactions to notify the authorities of the demise of COVERED PERSON in the event of accidental death.

b. Transportation of the body or mortal remains of the COVERED PERSON to the

specific location chosen by Beneficiary: The COMPANY, through one of its network providers, will arrange and assume the costs of local transportation of the body or mortal remains of COVERED PERSON to a funeral home and/or place of a wake or viewing. The COMPANY, through one of its network providers, will obtain the corresponding permits for such local transportation, if needed.

c. Transportation of the body or mortal remains of the COVERED PERSON to the

cemetery or crematory: If the BENEFICIARY of the deceased COVERED PERSON asks for this service, COMPANY will arrange and assume the costs of the transfer to the cemetery or crematory. Also, COMPANY will obtain necessary permits and assume corresponding fees. The COMPANY reserves the right to coordinate this with the entity providing the Funerary Services, where applicable.

2. If the U.S.A. is the final and chosen designation to take the body/remains of the COVERED

PERSON, the Company will provide the same basic services as set forth in Section II 1. above.

CAIC-GA-16 (01-2011) 3

III. Funerary Services Not Covered: All FUNERARY SERVICES are the responsibility of the BENEFICIARY and the surviving relatives of the deceased COVERED PERSON. FUNERAL SERVICES ARE NOT COVERED BY THIS ENDORSEMENT. Specifically, items not covered by this Endorsement include:

An upgraded casket other than the one the body is shipped in.

Makeup application to corpse (cosmetic arrangement) in Mexico or Central America and/or at the place the funeral is held.

Cost of Funeral Chapel or Funerary Parlor and related services and expenses incidental to a wake/visitation in Mexico or Central America and/or where the body is viewed.

Charges for the actual funeral service in the town/area where the COVERED PERSON is buried.

Expenses incurred for the cemetery, and/or cemetery site, plot or headstone. This includes any ongoing fees at a cemetery for upkeep or maintenance.

IV. Exception of Service.

1. Services herein described will not be provided in the following cases:

When the COVERED PERSON’s death is determined to be from natural causes or sickness. When the COVERED PERSON’s premium has not been paid or coverage has been cancelled by

the COVERED PERSON. If the COVERED PERSON’s accident or accidental death occurs somewhere other than within

the U.S.A.

V. Characteristics of the Service. Coordination of all services described herein will be for the repatriation of the body or mortal remains of the COVERED PERSON from the United States of America and to the Republic of Mexico or Central America and/or within the U.S.A., 24 (twenty four) hours a day, 365 (three hundred and sixty five) days a year. VI. Controversy. In the event of controversy regarding the cause of death of the COVERED PERSON, in relation to the Exception of Service, an action at law or in equity may not be brought to recover on this Endorsement before the sixty-first (61st) day after the date written proof of loss has been provided in accordance with the requirements of this Endorsement. An action at law or in equity may not be brought after the expiration of three (3) years after the time written proof of loss is required to be provided. VII. No Coverage for Named Insured’s Property. This Endorsement provides no coverage for any personal property or personal items of the COVERED PERSON. Beneficiaries should make separate arrangements to secure named insured’s personal items of value upon learning of such accident death. VIII. Accidental Death and Claim Notification Post Funeral. If the Beneficiaries first make a claim which is covered per the terms of this Endorsement, after the funeral of the COVERED PERSON and the repatriation feature of this Endorsement is not used, the Company will pay the Beneficiaries the Endorsement Limits. If this event occurs, the COMPANY has no other obligations or duties under this Endorsement.

CAIC-GA-16 (01-2011) 4

___________________________________________________________________________________________

REPATRIATION & DEATH BENEFIT _____________________________________________________________________________________________ LOSS BENEFIT Repatriation & Death Two options are offered:

Option 1 $6,000.00 US DOLLARS

Option 2 $10,000.00 US DOLLARS

_____________________________________________________________________________________________

DEFINITIONS _____________________________________________________________________________________________

“We”, “Us”, “Our”, or “The Company” means Commercial Alliance Insurance Company.

“Covered Person” means the Named Insured and drivers listed on the Application and Declarations Page of the Auto

Policy.

“Beneficiary” means the Covered Person’s Beneficiary set forth in the Endorsement Application. It will be deemed

plural if more than one Beneficiary is listed on the Application. The first Beneficiary listed on the Application has

sole authority to designate the location as to where the Covered Person’s body will be shipped.

“Repatriation” means if a person dies in the U.S.A., they are “repatriated” when their body is returned to Mexico

or Central America and/or designated place within the U.S.A. Repatriation insurance is used to prepare the body and

the body’s transportation expenses to the return of the Covered Person’s body/remains to Mexico or Central

America and/or within the U.S.A.

“Accident” means an auto accident, whether a passenger in a vehicle car or the driver of an insured vehicle; sudden

forceful unexpected and unintended event causing physical injuries which are the primary and principal cause of the

death of the Covered Person.

“Natural Causes and or Disease Process” means death caused due to either an ongoing physical process (for

example, diabetes, cancer or like deteriorating illness) or solely internal cause(s) (for example, heart or any organ

failure including stroke). A death by natural causes and/or disease process is not a death caused directly due to a

sudden and unexpected external physical blow or injury to the decedent’s body.”

“Accidental Death” means the death of the Covered Person, while in the USA, caused directly by accidental bodily

injuries. The accidental bodily injury or injuries must be the primary cause of death to the Covered Person as set

CAIC-GA-16 (01-2011) 5

forth in the official Death Certificate. To be an accidental death, The Covered Person must die as a direct result of

the injuries received within one (1) year from the date of such accident.

Solely for purposes of illustration or example, an accidental death, for the purposes of this Endorsement, can be any of the following:

Automobile, truck or motorcycle collisions. The Covered Person can be a driver or an occupant in, or a pedestrian struck by such types of motorized vehicles.

An accidental fall caused/causing bodily injuries and subsequent accidental death.

Accidental death by gunshot, but only if the Covered Person was a random victim of such event and/or criminal act.

Accidental death of the named Covered Person if the death is caused in the course of the insured’s work or employment.

_____________________________________________________________________________________________

EXCLUSIONS _____________________________________________________________________________________________ No benefits will be paid for death of the Covered Person resulting from any of the following:

1. Suicide, attempted suicide or intentionally self-inflicted injuries, causing death whether the Covered Person is sane or insane at the time of such events;

2. Declared or undeclared war or act of war;

3. Injury or death caused by intentional or unintentional armed conflict;

4. Riding or driving in any kind of organized race or racing event;

5. Participating in a riot; commission of or attempt to commit a felony or assault by the covered person;

6. Sickness or disease or medical or surgical treatment of sickness or disease including diagnosis, except when due to injury caused by a covered accident;

7. Bacterial infections except when caused by an auto accident or medical treatment of an auto accident

injury;

8. An accident occurring while the Covered Person is serving in any Armed Forces;

9. Travel or flight in, or getting in or out of:

an aircraft being used for test or experiment; a military aircraft and/or an aircraft the Covered Person is flying or is learning to fly or is part of the crew of the

aircraft.

10. Any disappearance or alleged disappearance of the Named Insured where the Covered Person’s body is not found.

CAIC-GA-16 (01-2011) 6

11. Natural causes and/or the result of a disease process.

12. This Endorsement is not renewable. There is no coverage once the Covered Person reaches the age 70. _____________________________________________________________________________________________

COMMON CARRIER BENEFIT

_____________________________________________________________________________________________ We will pay this benefit if:

1. Covered Person is injured in an auto accident which happens: a. while he or she is listed on the Declarations page of the Endorsement; and b. on any common carrier; and

2. Such Covered Person is not a pilot, crewmember or a non fare-paying passenger; and

3. Such Covered Person dies or is injured as a direct result and from no other cause within one (1) year

from the date of the accident. Entire Contract Changes: The Endorsement with the application[s], endorsements, riders, and attached papers is the entire contract between

the Policyholder and the Company. In the absence of fraud, statements made by the Policyholder or by a Covered

Person are deemed representatives and not warranties. No such statement will be used in a contest unless it is

contained in a written application. No change in the Endorsement will be valid until approved by the Company. This

approval must be endorsed on or attached to the Endorsement. No agent may change the Endorsement or waive any

of its provisions.

Legal Actions: No one may sue for benefits less than sixty (60) days after due proof of loss is submitted, not more than three (3)

years after the date claim forms are due.

Conformity with State Law: Conformity with State statutes of the U.S.A. only. Any provision of this Endorsement that, on its’ effective date,

conflicts with the statutes of the state in which the Covered Person resides on the effective date, is by this clause

effectively admitted to conform to the minimum requirements of that state’s statutes.

Examination of the Endorsement: A copy of the Endorsement shall be available for inspection by Covered Person during business hours at the Company’s office.

CAIC-GA-16 (01-2011) 7

Misstatement of Facts: If relevant facts about a Covered Person are not correct:

1. a fair adjustment of premiums can be made at the discretion of the Company.

2. and/or the true facts will decide whether and for what amount insurance is valid.

Endorsement of Insurance: The Company will issue to the Policyholder an Endorsement of insurance for each Covered Person covered by the Endorsement. The Endorsement will list the benefits, conditions, and limits of the Endorsement. It will state to whom the benefits will be paid. 30 Day Right to Examine Endorsement: If a Covered Person does not like his or her Endorsement, for any reason, he or she must return it to the Company

not more than thirty (30) days after he or she receives it. The Company will return any premium that he or she has

paid. In this event, the Endorsement will be VOID, as if it had never been issued.

_____________________________________________________________________________________________

PAYMENT AND NOTICE OF CLAIMS _____________________________________________________________________________________________ NOTICE Upon Beneficiary’s Notice of the accidental death of a Covered Person, they shall call 1-888-334-0114 to report the

death and make a claim.

Claim Procedures: Notice of Claim: Time is important, and Beneficiary should notify the Company, as soon as possible, of the Covered Person’s death. Upon the death of the Covered Person, the Company should receive written notice as soon after that as is reasonably

possible. This notice should state the Endorsement and/or endorsement number, the Covered Person’s name and date

and alleged cause of death, if known. This notice should be sent to the Company at the address shown on this

Endorsement or to an agent authorized by the Company. The Company will send the Beneficiary claim forms and

immediately seek a Death Certificate to aid in determine the cause of the Covered Person’s death.

CAIC-GA-16 (01-2011) 8

Physical Examination and Autopsy: At the Company’s expense, the Company may have the deceased Covered Person’s body examined as often as

reasonably necessary while a claim is pending. The Company may also request an autopsy in case of death where it

is not forbidden by law. An autopsy could assist in determine the cause of death. Any costs of an autopsy required

by the Company are solely the responsibility of the Company.

Right to Have Copy of Death Certificate: The Company has the right to have a copy of the official Death Certificate before making a determination as to

whether the Covered Person’s death is a result of an accident. The process to determine the cause of the Covered

Person’s death begins, upon the Company’s receipt of the official Death Certificate.

Claim Procedures: Proof of Loss: For a claim, for a loss for which this Endorsement provides any periodic payment contingent on continuing the loss,

a written proof of loss must be provided to the insurer at the insurer’s designated office before the ninety-first (91st)

day after the termination of the period for which the insurer is liable. For a claim for any other loss, a written proof

of loss must be provided to the insured at the insurer’s designated office before the ninety-first (91st) day after the

date of the loss. Failure to provide the proof within the required time does not invalidate or reduce any claim if it

was not reasonably possible to get proof within the required time. In this event, the proof must be provided as soon

as reasonably possible but not later than one (1) year after the time proof is otherwise required, except in the event

of a legal incapacity.

Payment of Claims: When Paid: The Company will pay claims immediately upon proof of loss with the death certificate, and an investigation having

verified the Covered Person’s death was accidental. The Company will notify the Beneficiary of either acceptance of

the claim or the reason for denial no later than ten (10) business days from the receipt of the Death Certificate by the

Company. The only exception to this ten (10) business day time frame is the need for an autopsy. An autopsy will

extend the Company’s time to accept or deny a claim. The Company has five (5) business days, after receipt of an

autopsy report, to accept or deny a claim. In the event of payment, the Beneficiary agrees to assist in the

arrangements and timing of the shipment of the Covered Person’s body/remains. The remainder of the endorsement

limits after deducting $6,000 Dollars for the Repatriation Service will be sent directly to Beneficiary, at the address

listed on the Application, upon acceptance by the Company, of a claim.

CAIC-GA-16 (01-2011) 9

Payment of Repatriation: To Whom Paid: Benefits paid on account of a Covered Person’s death after repatriation will be paid by the Company and the Beneficiary he or she has chosen. The First Beneficiary on the Application has sole authority to determine where the Covered Person’s remains will be sent. This choice must be in writing and filed with the Company, or with the Program Administrator. If the Covered Person has not chosen a Beneficiary or if there is not a Beneficiary alive when the Covered Person dies, the Company will pay the repatriation benefit in the following order with the entire remainder of the endorsement limits after deducting $6,000 Dollars for the Repatriation Service benefit paid to:

1. wife or husband of Covered Person; but if not living to 2. child or children of Covered Person (split equally among the living children of the Covered Person);

but if not applicable to 3. mother and/or father of Covered Person; but if not applicable to 4. sisters and/or brothers of Covered Person (split equally among the living sisters or brothers of the

Covered Person). If no one in the above classes is living, the repatriation benefits will be paid according to the wishes of the Consulate of Mexico or Consulate of the respective country of Central America. The Company has no further obligation or duty to find a living relative of the Covered Person. Beneficiary: Changes and Need to Notify Company Before Death of Covered Person: The Covered Person has the right to select or change the Beneficiary or decision maker in the event of the Covered

Person’s death. The original and/or existing Beneficiary’s consent is not needed for the Covered Person to make a

change of Beneficiary. Any such selection or change by the Covered Person must be in writing and presented to the

agent of record, for this Endorsement. The Company will not be bound until the Company has received a signed

copy of such change. No such change will be honored if such written change is first received by the Company after

the death of the Covered Person, and this applies regardless of the date when the change was allegedly made.

Payment Made: Any payment made by the Company, in good faith pursuant to this provision, shall fully discharge the Company to

the extent of such payment.

_____________________________________________________________________________________________

CANCELLATION BY COVERED PERSON _____________________________________________________________________________________________

This Endorsement may only be cancelled by the Named Insured. The Named Insured may cancel this Endorsement

by mailing a request for cancellation to the Company at the address shown in this Endorsement. The effective date

of cancellation stated in the notice will become the end of the Endorsement period. Return of earned premiums will

be computed pro-rata based on the number of days left on the endorsement term. The Company’s check or the check

of the Company’s representative mailed or delivered to the Covered Person will be sufficient tender of any refund of

premium.

CAIC-GA-16 (01-2011) 10

_____________________________________________________________________________________________

LEGAL ACTIONS _____________________________________________________________________________________________

No action or law or in equity can be brought until after sixty (60) days following the date written proof of loss was

given. No action can be brought after three (3) years from the date written proof is required.

_____________________________________________________________________________________________

INADVERTENT ERROR _____________________________________________________________________________________________

The insurance of a Covered Person will not be prejudiced by the failure on the part of the Company to transmit

reports, pay premium or comply with any of the provisions of this Endorsement, when such failure is due to an

inadvertent error or clerical mistake.

CAIC-GA-15 (01-2011)

COMMERCIAL ALLIANCE INSURANCE COMPANY

NAMED DRIVER EXCLUSION OF COVERAGE

THIS ENDORSEMENT CHANGES THE POLICY. THE DRIVERS LISTED BELOW WILL NOT HAVE COVERAGE. THIS FORM BECOMES PART OF YOUR POLICY. PLEASE READ IT CAREFULLY. IF YOU HAVE QUESTIONS, PLEASE ASK YOUR AGENT.

Excluded Driver(s) First Middle Last Name Date of Birth Relationship All regular drivers, members or residents of the household age 14 and older must be rated for coverage or excluded from coverage. I agree with the company that no coverage for any claim arising from an accident or loss incurred when a covered auto or any other auto is operated, maintained, or used by a driver(s) specifically excluded from coverage at the time of application or by endorsement. This exclusion applies whether or not the use is with my permission. This includes any claim for damages made against me, or a family member or resident or any other person or organization for negligent entrustment, vicarious liability, or any other similar theory. This exclusion under this policy will apply to all renewals and changes thereof. Accepted By Policyholder Signature Policy Number Endorsement Effective Date

Administered by

Georgia Automobile Insurance Identification Card

Commercial Alliance Insurance Company

POLICY NUMBER

EFFECTIVE DATE

Applicable with respect to the following Vehicle: EXPIRATION DATE

Year Make Vehicle ID Number

Office issuing this card:

SEE IMPORTANT MESSAGE ON REVERSE SIDE CAIC-GA-12 (01/11) THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE. THE CURRENT STATUS OF THE ACTUAL MOTOR VEHICLE LIABILITY INSURANCE COVERAGE IS MAINTAINED BY THE GEORGIA DEPARTMENT OF MOTOR VEHICLE SAFETY AND IS ACCESSIBLE TO LAW ENFORCEMENT UPON A CHECK OF THE VEHICLE REGISTRATION. WARNING: Any owner or registrant of a motor vehicle who drives or permits a motor vehicle to be driven in the State without the financial responsibility may have his registration suspended or revoked. NOTE:THIS CARD IS REQUIRED WHEN: (a) You are involved in an auto accident. (b) You are convicted of a traffic offense other than a parking offense that required a court appearance. (c) Upon request of a police officer. You must provide a copy of this card to the Department of Transportation when you request restoration of your operating privilege and/or registration privilege which has been previously suspended or revoked. IF YOU HAVE AN ACCIDENT - NOTIFY POLICE IMMEDIATELY 1. Write down names, addresses, telephone numbers and license numbers of persons involved and of witnesses. Remain at scene until police arrive. 2. Notify CIS, Inc. promptly. 3. Do not admit fault, do not discuss the accident with anyone except CIS, Inc. CHAPPELL INSURANCE SERVICES, INC. Telephone Number: 1-800-236-8599 CAIC –GA-12 (01/11)

CAIC-GA-09 (01-2011)

COMMERCIAL ALLIANCE INSURANCE COMPANY

Administered by: CIS, Inc. P. O. Box 8910

Savannah, GA 31412 800-280-0955

PRIVACY NOTICE

Legal Disclaimer NOTICE OF COMMERCIAL ALLIANCE INSURANCE COMPANY (CAIC) POLICY ON HOW WE USE & PROTECT YOUR PERSONAL INFORMATION

Dear CAIC customer:

In compliance with U.S. Federal Law, CAIC provides you with this notice concerning how we use and protect your personal information.

What do we do with the personal information we collect about you? CAIC does not disclose any of your personal information to any companies or any organizations not affiliated with us that could use that information to contact you about any of their own services or products.

Unless we receive written notice from you at the address listed below to share information about you to anyone who could use your personal information found in our files for marketing or insurance, CAIC will not share that information.

CAIC may use your personal information to communicate with you about products, features or options that we believe that you may have an interest in. We may, as permitted by law and without your prior permission provide personal information about you contained in our files & records to organizations such as:

- Your insurance agent or broker - Organizations who perform a business function for us - Insurance support organizations - Other insurance companies that have a role in a transaction involving your policy - Insurance claims adjusters

- Research or actuarial studies - Government, law enforcement or regulatory authorities - Rental or repair shops or similar vendors - Persons requesting data pursuant to legal, subpoena or court order - Other affiliated companies

What kind of personal information do we have and where did we get it? Much of the information we have came from you such as the application or other requests for insurance and may have contained data such as your address and phone number. We also may have your payment history and account balances. We may have information from your agent or other affiliated companies on your name, address, date of birth, driver's license number, credit card number, social security number and other personal information from accident reports, medical records, vehicle information and other data that CAIC and its affiliates may have received. We may also collect personal information from other outside sources including consumer reports, health care providers, motor vehicle reports and other agencies.

How do we protect your personal information? When we share information with companies working on behalf of CAIC we protect that personal information as required by law and ask that those same requirements are kept confidential on any information about you that we give out. Within CAIC, your personal information is available to those individuals who may need to see it to service the needs of CAIC customers. We have communicated the need to protect this data to those individuals who have access to this data and we have electronic and procedural safeguards to protect your information.

Your personal information will remain protected here at CAIC. You may request to obtain your personal information we have about you in our records and that you may request to have corrections, additions or deletions made to disputed personal information. We may make arrangements with a support agency to copy and disclose personal information to you on our behalf. You may request to whom we disclose your personal information about you or the circumstances that warranted those disclosures. Written requests are to be sent in writing to:

Commercial Alliance Insurance Company 415 Lockhaven Drive Houston, Texas 77073

CAIC-GA-DEC1 (01/2011)

Commercial Alliance Insurance Company NAIC# 10906

PERSONAL AUTOMOBILE POLICY

Agency Name and Address Agent #:

This Declarations Page, along with the Policy and the following policy provisions forms, completes this policy. This Policy provides only those coverages for which a premium is shown below.

Named Insured and Address

Full Term Premium Charge

Total Policy Premium = $ Transaction Premium = $

Coverages and Limits

Limits

A Personal Liability Bodily Injury* Property Damage *Per Person/Per Accident

$25,000/50,000 $25,000

B Medical Payments $ Medical Limit

__ Option I __ Option II

C Uninsured Motorists** Bodily Injury* Property Damage

*Per Person/Per Accident ** Deductible applies

__Reduced __ Added On $25,000/50,000 $25,000

__250 __ 500 __ 1000

D Comprehensive $ Deductible

E Collision $ Deductible

Other Coverage(s) Rental Reimbursement per day max

Towing and Labor per disablement

Repatriation*

*Named Insured Only

TOTAL VEHICLE PREMIUM

Coverages only apply where a premium is shown

Policy Number Policy Period From To New Declaration Effective Date Control Number

Administered by

CAIC-GA-DEC1 (01/2011)

Description of Driver(s)

Driver #

Driver Name Status

DOB

Senior Driver Discount SR 22

Description of Your Auto(s)

Veh#

Year

Make

Model

VIN

Sym

Class

Garaged Territory

Code

Safe Vehicle

Discount

Forms and Endorsements

The following endorsement(s) are considered part of your policy: Form Number and Endorsement Name Other optional coverages are available; please contact your agent for information.

Additional Policy Information

Discounts Applied to Policy

Loss Payee/ Additional Insured

Veh#

Loss Payee Clause

Loss or damage under this policy shall be paid as interest may appear to you and the loss payee shown in the Declaration. This insurance

with respect to the interest of the loss payee shall not become invalid because of fraudulent acts or omissions unless the loss results from

conversion, secretion or embezzlement of your covered auto. However, we reserve the right to cancel the policy as permitted by policy

terms and the cancellation shall terminate this agreement as of the loss payee’s interest. We will give the loss payee 10 days notice of

cancellation.

When we pay the loss payee for loss which you are not covered we shall, to the extent of our payment, be subrogated to the loss payee’s

rights of recovery against you.

Countersignature

Date

COMMERCIAL ALLIANCE INSURANCE COMPANY VEHICLE INSPECTION FORM – GEORGIA

CIS, INC. PO BOX 8910

Savannah, GA 31412-8910 Phone (800) 280-0955 ◊ Fax (912) 236-8397

One form per vehicle on policy is required.

Please indicate on the above car the location of any old damage. Use an “S” for

any scratches or an “X” for any broken glass or damaged panel.

If damage is present, two photos are required to be submitted with the application along with agent and insured signatures.

Policy Number:_________________________________ Insured Name_______________________________________

Vehicle #__________________ Year______________ Make/Model________________________________________

VIN #__________________________________________

License Plate - State & # _______________________________ Odometer Reading ______________________________

Vehicle Condition: □ Excellent □ Good □ Fair □ Poor

Describe any damage on the vehicle including which panel is involved: ________________________________________

X_________________________________________________ X__________________________________________ Agent Printed Name Applicant Printed Name

X_________________________________________________ X__________________________________________ Signature of Agent Date Signature of Applicant Date

CAIC 007 (09/10)

please fax all information to (912) 236-8397. thank you for your...

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