@@@@@@@@@ SURCHARGE NOTICE :»»»»»>

The AHTCA MUTUAL I NSURANCE COMPANY (354 ) Insurance Company hereby nOlllles the OPERATOR named below that an at-fault acclaenl claim (eccra Is being reported to the Merit Rating Board. A aetermlnatlOn has been made that the OPERATOR is more than 50% at fault for the accident described herein.

This ai-fault accident may result in an increase in auto insurance premium in furlu re.

OPERATOR INFORMATION

Change of Address (enter corrections here)

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Address \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ »»»»»»»»»» » »»»» » »»»» City, State

City. State @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Zip

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Dateol Driver"s State

Birth «««« License No. \\\\\\\\\\\\\\\\\\\\\\\\\ Code ¢ II any of Ihe above operator Inlormatlon is incorrect, do not appeal. Contact your insuran.ce company 10 make the appropriate corrections.

ACCI DENT I NFORMATI ON ""'C,U"I I.<l<.al"" Policy No Cia" .. No , .. HOI",. D_ COd.

@@@@@@@@ «««« \\\ »»»»»> @@@@@@@@@@@@@ StaMard 01 h~1I Code 1« I E.laRabon 1 ~\\\\~~\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ »»»»»»»»»»»»»»»»»»»»»»»»»»»»»» @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ «««««««««««««««« « ««««««« « «««« «

APPEAL INSTRUCTI ONS IF YOU BE LI EV E YOU WERE NOT MORE THA N 50% AT FAU LT IN THIS A CC IDENT AND WISH TO APP EA L TO THE MASSACHUSETTS DIV IS IO N O F INSU RA NCE, YOU S HOULD: o Complele Ihe Appeal Form on Ihe reverse Side oflhis nottce. File only one appeal per accident. o Send a ctleek or mOfley order for $50.00 payable to the Commonwealth of Massachusetts. ThiS liIing fee is non-refundable.

The Division of Insurance does not accept cash. o Return thiS completed form with the filing fee by mail to: DIVISION OF INSURANCE

P.O. Box 370009 BOSTON, MA 02241-0709

¢ A request for appeal must De SUbmitted and received WITHIN 30 DAYS of the Notice Date.

»

o Do not submit additional documents or mater ialS with thiS form. All additional documents or materialsmust be presen ted at the of the hearing.

o Your cancelled Check or money order will serve as your recelpt of Ihe appeal.

<> The DIVis ion of Insurance wi ll notify you as to Ihe date, time, ana location of your heaflng.

<> Filing an appeal does not prevent an increase in premium for thiS at-fault accident. II the increase 1$ billed, It must be paid. If It is later reverSed, your premium Will be adjusted, and the amount paid Will be refunded or credited by the Insurance Company.

Reasonable accommOdations for people With disabil ities are available upon request. Contact the Board 01 Appeal at lease ' 4 days In advance o f the hearing date with a deSCription 01 the accommodation you require. Send an email to boa .mai lbo~slate.ma.us or cau 617 52'-7478.

POLI CYHOLDER (I I dillerent than INSURANCE AGENT the OPERATOR)

Date of Birth Dflver's License NO, State Code Phone

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Name \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ \ Name \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ Address »»»»»»»»»»»»»»»»»»» ;;Address »»»»»»»»»»»»»»»»»»»

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ City, Stat ««««««««««««««««««« ~ity, State «««««««««««««««««««

Z,p Zip

MAOO6302,2

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SURCHARGE APPEAL FORM The OPERATOR should provide as much of the following accident information as possible: PLEASE PRINT

ACCIDENT INFORMATION _I Time DAM o PM Number of vehicles involved No. of lanes in

Location - -- each direction CITY/TOWN STATE STREET

No. of lanes in If intersection , intersection street each direction Your speed prior to the accident mph Posted speed mph

SIGHT LINES/DISTANCE I When you lirst saw the other vehicle, how far were you from it? If a rear end collision, give d istance between you and the vehicle you were following prior to the accident. If an intersection colli sion, give your view in distance to right to left before entering intersection.

PQUCE . j at accident scene? oNO DYES Were you issued a citation ('ticket')? o NO DYES

DAMAGE (example - passenger side rear door )

To the vehicle you were driving

To other vehicle Identify damaged property other than vehicles

TRAFFIC CONTROL III LIGHT CONDITIONS I WEATHER I 0 Oaylight o Clear DRain 0 Dawn o Cloudy o Sleet 0 Dusk o Fog o Snow 0 Dark o Mist o Hail

o Traffic Ught o Slop Sign o Yield Sign o Fl ashing Light

o None o Construction area o Officer/Guard o Other

ROADWAY' SURFACE-""- I'; I

DOry o Slush

o Sand o Mud

o Snowllce o Wei o Other

PROVIDE DETAILS OF HOW THE ACCIDENT HAPPENED

STATE REASON(S) WHY YOU BELIEVE YOU ARE NOT MORE THAN 50% AT FAULT FOR THE ACCIDENT

I , the Operator n~med 1I ... ,n, being aggri t!Vl!d by the det.rmination Qlthe i Slu,ng ;nsur~nce company that 1 have been lo~nd to btl more than 5(1 % at fa~1t lor thl ~ccident identIfIed In th is notICe, do hereby appeal Ih l insurance comp~ny's d.l~rmln<lt l on of fau lt In eKCISS 01 5(1% pursuant 10 Chapter 175, sect ion 113P of the

Massachusl Us Genlr~1 Laws 1 hereby dlclare thl IQrl90ing Informallon and stalemlnts arl made under Ih, pains and penalillU 01 perjury

x OPERATOR'S SIGNATURE DATE

Home telephone NO. ( Work telephone No. ( )-------- - ''''. Do not submit additional documents or materialS with this !orm. All additIonal documents or matenalS must be presented at the lime 01 the hearmg.

@@@@@@@@@ SURCHARGE NOTI CE »»»»»>

Tne AI1ICA MUTUAl, INSURANCE COMPANY ( 354 ) Insurance Company hereby notifies the OPERATOR nameo below that an ai-tau!! aGC!deot claim (regen is being reoorteg In !he Mer;! !lateM Rooct! A determination /\as been made that me OPERATOR 1$ more than 50% at fault lo r the aC(;I(1ent descr ibeCi herein.

This at-taylt accident may result in an increase in auto insurance premium in fUrture.

Change 01 Address (enter corrections here)

Name ««««««« «« «««««««««« « Address

AOcIress """""""""""""""""""" »»»»»»»»»»»»»»»»»»»» City, Stale

City, State @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Zip

Zip

Dale 01 Dnver's State

R"m «««« , N< """""""""""'" Co

~O~I:~.' yo'"~ho ",0., , , " mOk. ;~~ i , do 001 "p"l.

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IF YOU BELI EVE YOU WERE NOT MORE THAN 50% AT FAU LT IN THIS ACCIDENT AND WISH TO APPEAL TO THE MASSACHUSETTS DIV ISION OF INSURANCE, YOU SHOULD: o Complete the Appeal Form 00 the reverse Side of this Ii , Lisend a check or money orCler lor $50.00 payabte to the fee is non·refundable. -rhe DiviSion of Insurance does not accept caSh. o Return thiS completed form with the filing lee Dy mail to: DIVISION OF IN SURANCE - P.O. Box 370009

BOSTON, MA 02241-0709

.2.,A reQuest lor appeal must be suDmllled and reCeived WITHIN 30 DAYS of tl"le Notice Date.

»

o Do not submit additional documents or materialS witl"l this lorm. All addit ional documents or materialsmust De eresented at the 01 the hearing,

o Your cancelled check or money order will serve as :i0ur recelet of the aeeeal.

() The DIVision of Insurance will notify you as to the date, t ime, and location of your heating.

> ~Ih i ,,", ,,," . "" """ , " I i ; I II , I , I "

"" . ,m i i "" I i , I

POLICYHOLDER l~.di ,I moo I NSURANCE AGENT I

Date 01 Birth Dflver·s Ucense No. Phone

"""" »»»»»»»»»»»»> @@ «« « «««

Name """"""""""""""""""" I' Name """"""""""""""""""" Clly, " , S,,"

Zip Zip

MA 00 63.2.t.!!..

,

SURCHARGE APPEAL FORM The OPERATOR should provide as much of the following accident information as possible: PLEASE PRINT

ACCIDENT INFORMATION I Time D AM D PM Number of vehicl es involved No. of lanes in

location - - - each direction CITYtTOWN STATE STREET

No. o f l anes in If intersection, inter section street each direction Your speed prior to the accident mph Posted speed mph

SIGHT LINES/DISTANCE I When you first saw the other vehicle, how far were you from it? If a rear end collision, give distance between you and the vehicle you were following prior to the accident. If an intersection collision, give your view in distance to right 10 left before entering intersection.

pQLlCE}, I at accident scene? DNO DYES Were you issued a ci tation rticket~)? o NO DYES

DAMAGE (example - pa ssenger side rear door)

To the vehicle you were driving

To o ther vehicle Identify damaged property other than vehicles

TRAFFIC CONTROL III LIGHT CONDITIONS I WEATHER I o Traffic Ught 0 None 0 Daylight o Clear 0 Rain o Stop Sign o Construction area 0 Dawn o Cloudy o Sleet o Yield Sign o Officer/Guard 0 Dusk o Fog o Snow o Flashing Ught o Olher 0 Dark o Mist o Hail

o Dry o Slush

o Sand o Mud

o Snowllce o Wet o Other

PROVIDE DETAILS OF HOW THE ACCIDENT HAPPENED

STATE REASON(S) WHY YOU BELIEVE YOU ARE NOT MORE THAN 50% AT FAULT FOR THE ACCIDENT

I, Ille Operator named lI!rein. being iIIgriev.d by tile determination 01 tile iSSUi ng insu rance company that I have bun found to be mort than &1% at laull for the acc,dent ldlnltfied in thi s notice. do hl reby appeal the insurance company's dl term,nation of fa ult In IJ(cess 01 &1% pursuant to Chapter, t75. Slction ~ 01 thl MassachU$ltts General Laws. I hereby dl clar. the forego ing Informat ion and statemlnts ara made under th l pains and pecnalltlls of perjury

x OPERATOR'S SIGNATURE DATE

Home te lepnone No. ( Work telephone No. ( 1 _ _ -_____ _

Ext.

Do not SUbmit additional documents or materialS With tn l5 form. All additional documents or materials must be presented at the time of the nearing.

@@@@@@@@@ SURCHARGE NOTICE »»»»»>

The ( 354 ~ Insurance Company hereby noti fies the OPERATOR named below thaI surCharge maybe imposea as reQuired by M.G.l. c. 175 § 1 13B,~ determination has been made that the OPERATOR IS more than 50% at fau lt for the acCident described herein.

@ is surCharge may result in an increase in premium when an insurance policy is next renewed for any vehiC~ on which the OPERATOR is listed.

Name

Address

OPERATOR INFORMATION

«««««««««««« « ««««««« \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ »»»»»»»»»»»»»»»»»»»»

C,ty. Stote @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Zip

Date 01

Birth ««««

Surd .. ,. Nobe. Do'.

Driver's

license No. \\\\\\\\\\\\\\\\\\\\\\\\\ o II any of the above operator information is il'lCOrreC1, (\0 nOI appeal. COnlact your insurance company to make the appropriate corrections.

toc ... on CU.

ACCIDENT INFORMATION ~1'<yH". CI. i ... No

@@@@@@@@ «««« \\\ »»» » »> @@@@@@@@@@@@@ S,.ncI.,d 01 F,u!1 COdo 1« I E><p!oMlMln: I \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ »»»»»»»»»»»»»»»»»»»»»»»»»»»»»» @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ « «««««««««««««««««««««««««««««

I SURCHARGE I APPEAL INSTRUCTIONS IF YOU BELIEVE YOU WERE NOT MORE}~AN 50% AT FAULT IN THIS ACCID ENT AND WISH TO A PPEAL TO THE MASSACHUSETTS DIVISION OF INSURANCE, YOU SHOULD:

((NlCompJele thersurchar~peaJ Form on Ihe reverse SIde 01 this notice. [B}send a checlc~r money order lor $50.00 payable 10 Ihe Commonwealth o( njassachusells. ThiS fIling fee is non·refundable. (;",.:;.{ile only one appeal per accident. T~e DiviSIon of Insurance does not accept caSh. U£UReturn tnlS completed form Wltn tne IIImg fee by mal l to: DIVISION OF INSURANCE

P.O. Box 370009

BOSTON, MA 02241 ·0709

f("QllA request lor appeal must be subrmlle<:i and received WITHIN 30 DAYS 01 the@UrCharQi}Nohce Date. m..Drne DiviSion of Insurance will notify you as (a the date, t ime, and location 01 your hearing.

Stale

COde »

roFlhng alSurcharg~appeal dOeS not prevent the appl ication 01 the surcharge to the premium. li the surcharge is blUed, It MUST be paid] \....!.I II IS lolfer reversed, your premium will be adjusted, ana the amount paid Win be refunded or credited by the Insurance Company.

~ - ~ II the operator 'S mailing address is different than the ~ ADDRESS address Shown Stieve, ptease indicate corrections here

CITY. STATE ZIP

POLI CYHOLDER

Date of Birth Driver's License No.

(i f different than the OPERATOR)

State Code Phone

INSURANCE AGENT

\\\\\\\\ »»»»»»»»»»»»> @@ ««««««

Nome \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ Nome \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \

Address »»»»»»»»»»»»»»»»»»» ;;AClClress »»»»»»»»»»»»»»»»»»» >

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @ CIty, Stat ««««««««««««« « ««««« ,elly, Stale ««««««««««««« « ««««« < • •

SURCHARGE APPEAL FORM The OPERATOR should provide as much of the following accident information as possible' PLEASE PRINT

ACCIDENT INFORMATION Time DAM OPM Number of vehicles involved No. of lanes in

Location - - - each direction CITY/TOWN STATE STREET

No. of lanes in If intersection, intersection street each direction Your speed prior to the accident mph Posted speed mph

SIGHT UNESIDISTANCE When you first saw the other vehicle, how far were you from it? If a rear end collision, give distance between you and the vehicle you were following prior to the accident. If an intersection colli sion, give your view In distance to right to left before entering intersection.

;:::::, ~Qt:l.GE< ' :: :; ,:· : · at accident scene? ONO DYES Were you issued a citation nickel')? o NO DYES

DAMAGE (example - passenger side rear door)

To the vehicle you were driving

To other vehicle Identify damaged property other than vehicles

BEFORE TH-E ACCIDENT YOUR CAR WAS 1.1 LIGHT CONDITIONS • o Going straight ahead o Making a right turn o Merging o Daylight o Starting from parked position o Turning right on red o Changing lanes o Dusk o Avoiding object in road o Making a U-turn o Overtaking another vehicle o D.rtnghtedr~ o Starling from stop sign o Stopped in traffic o Backing r:8. Dar li hted area o Starting from traffic control o Slowing or Stopping o Other o other o Making a left turn o Parked 0 - -TRAFFIC CONTROL • ROADWAY SURFACE 10/ WEATHER • o Traffic light o None o Dry o Sand o Clear D Rain o Stop Sign o Construction area o Slush o Mud o Cloudy ~ Slee"".iI o Yield Sign o Officer/Guard o Snowllce o Wet o Fog Snow -o Flashi~ ~ht o Other o Other o Mi st Other

PROVIDE DETAILS OF HOW THE ACCIDENT HAPPENED

STATE REASON(S) WHY YOU BELIEVE YOU ARE NOT MORE THAN 50% AT FAULT FOR THE ACCIDENT

An appeal must be submitted and received Within 30 days 01 the Surcharge Notice Date. I. the Operator named her.in. biting a9!lri..-td by Ihe d.termlnatlon of the iS$uingln surance company that I have bitl!n found to b. m an 50% at fault!2[ the aceident identified in thi s surcharljl notice. do hereby appeal til. insurM" company's determination of fault in I~cess of 50% pursuant to Chapl.r 17~. S~1 10<I1I!.3!:!Pf the Massachusetts GIlnera! Laws_ ! h.reby d8(lare the foregoinlj information and statemlnts art made under the pains and penalllles 01 perjuly

x OPERATOR'S SIGNATURE DATE

Home telephone NO. ( Work telephone No. ( ) __ - ________ Ext.