Additions:

Year	Make	Model	VIN ID#

Car Usage:

Pleasure:                                      Work:                                 If work, miles one way:

Loss Payee:

Loss Payee Address:

City:State:Zip Code:

Is this vehicle leased? YES  NO                                           New Cost: $

Registered Owner:

   

Coverages: Fill in ALL amounts

Bodily Injury:	Property Damage:	CSL Liability:
Uninsured/Underinsured Bodily Injury:	Medical Payment:	Uninsured Motorist Property Damage:
Towing:	Car Rental Coverage:	Loan Lease Gap Coverage:

Please Check Box for Deduction Information:

Comprehensive		No Coverage		Yes	Deductible: $
Collision		NoCoverage		Yes	Deductible: $

Deletions:

Year	Make	Model	VIN ID#

Please read and be sure all information is correct, then sign the form and return it to our office:

A.        I understand that higher limits are available for the following auto coverages:                                                                                                                     1.         Bodily Injury                                                           2.         Property Damage                                                           3.         Medical Payments                                                           4.         Uninsured Motorist Bodily Injury                                                           5.         Uninsured Motorist Property Damage                                                           6.         Underinsured Motorist Bodily Injury   B.         I understand that the limits shown on this change sheet are those that I have selected, and I will            be personally liable for any amounts of claim(s) over and above the limits selected.

BE AWARE that all companies run a MVR/Clue Report on the all prospective clients.  In connection with this application for insurance, we may review your credit report or obtain or use a credit based insurance score based on the information contained in that credit report.  We may use a third party in connection with the development of your insurance score.  Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties.  You have the right to review your personal information in our files and can request correction of any inaccuracies.  A more detailed description of your rights and our practices regarding such information is available upon request.  Contact your agent for instructions on how to submit a request to us. Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. By my signature (initials), I declare that the information provided to JMS Insurance is true, complete and correct to the best of my knowledge and belief.  I understand any incorrect information may result in a higher insurance premium or denial of insurance by company.

Signature

Date