lAPPLICATION NUMBER RIN1717811AMERICAN BANKERS INSURANCE COMPANY OF FLORIDA11222 Quail Roost Drive, Miami, FL 33157 -6596 (305) 253-2244RENTERS INSURANCE APPLICATIONApplicants NameRequested Coverage Effective DateRobel Regassa2012-07-22Applicants Insured Address and Unit/Apartment Number, City, State, ZIP Code9332 EDMONSTON RD 104, GREENBELT, MD 20770Mailing Address (if different from insured address), City, State, ZIP CodeApplicants Phone Number (571)314-0227Construction Type: N/AE-Mail Address robel.
[email protected] of Dwelling: Apartment/CondominiumInterested Party NameN/AInterested Party AddressN/APERSONAL PROPERTY COVERAGEState: MD$5, 000 Personal Property CoverageReplacement Cost Coverage INCLUDED. Sewer or Drain Backup Coverage NOT INCLUDED. Term of Coverage: 1 YEAR. PAYMENT METHODCredit CardVisaXXXXXXXXXXXX431402/2015Payment Plan Option: 81 Initial Payment of $14. 567 Installment Payments: $14. 92A $15 policy fee, if applicable, is included in your premium. Payment Plan Options are available to all Payment Methods.
If installment payment plan is chosen, a $4. 00service fee is included in each installment. The service fee of $4. 00 is not applicable to the initial payment. In addition to Personal Property Coverage, I understand the plan includes $100, 000 Personal Liability, $500Medical Payments per Person to Others, $500 Property Dama ge to Others, and a $250 deductible will be appliedto Personal Property Coverage under all plans. This policy provides only limited coverage for certain classes ofproperty.
By typing my full name below as it appears on my account to be billed, I req uest enrollment in Renters Insuranceand authorize the billing of the cost of the insurance to my account to be billed. I agree to the use of electronicenrollment and intend the use of the electronic signature that follows to evidence my consent of this e nrollment. I consent to entering into this insurance transaction electronically via the Internet. I also consent to be notified bye-mail at the indicated e-mail address regarding this insurance, including the status of my insurance application.
Applicants Electronic Signature Robel RegassaAgents Name (if applicable)Agent??™s License Number (if applicable)Application Date 07/21/2012Agents NumberCopyright ?©2005 American Bankers Insurance Company of Florida”Coverage for this policy is effective as follows: 1. If the application is sent via facsimile or internet, 12: 01 AM thefollowing business day after the Company receives the application and payment; or 2. The requested coverageeffective date on the application if that date is later than the dates specified in 1. Additionally, all effective datesare subject to Company moratoriums. A4009-1007Tracking CodeCopyright ?©2005 American Bankers Insurance Company of Florida”FRAUD NOTICEAny person who knowingly and with intent to defraud any insurance company or other person files an applicationfor insurance or statement of claim containing any materially false information or conceals, for the purpose ofmisleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is acrime, and may subject such person to criminal and substantial civil penalties. (Applicable in AR, HI, LA, ME, OH, TN and VA)Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement ofclaim or an application containing any false, incomplete, or misleading information is guilty of a felony of the thirddegree.
Kentucky: Any person who knowingly and with intent to defraud any insurance company, or other person files anapplication for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commit a fraudulent insurance act, which is a crime. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss orbenefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crimeand may be subject to fines and confinement in prison. New Jersey: Any person who includes any false or misleading information on an application for an insurancepolicy is subject to criminal and civil penalties. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit orknowingly presents false information in an application for insurance is guilty of a crime and may be subject to civilfines and criminal penalties. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other personfiles an application for insurance or statement of claim containing any materially false informationor conceals for the purpose of misleading, information concerning any fact mater ial thereto commits afraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties . Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a lossor benefit or knowingly presents false information in an application for insurance is guilty of a crimeand may be subject to fines and confinement in prison. Washington, D. C.
: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO ANINSURER FOR THE PURPOSE OF DEFRAUDING T HE INSURER OR ANY OTHER PERSON. PENALTIESINCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITSIF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurancecompany for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial ofinsurance benefits. Applicants Electronic Signature Robel RegassaAgents Name (if applicable)Application Date 07/21/2012Agents NumberTracking CodeCopyright ?©2005 American Bankers Insurance Company of Florida
