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Click here or scroll down to respond to this candidatePolicy and premium information for policy numberAgent:Insurance Company:TOOLEY & CARVER INSURANCEStreet Address Street Address
LAFAYETTE, TN Street Address -0660410499PHONE NUMBER AVAILABLENamed Insured(s): CAMERON HARRISLAFAYETTE, TN 37083305 MAIN STLAFAYETTE, TN 37083Garaging Address: 305 MAIN STTuesday, May 30, 2023 12:42:00 PM CSTTotal Policy Premium: $713.00Initial Payment Received: $178.25$534.75Payment Plan: 25.00% Down - 5 PayDrivers and Household ResidentsOutline of CoverageTrexis Insurance CorporationP.O. Box 682322Franklin, TN 37068EMAIL AVAILABLEHome: PHONE NUMBER AVAILABLEThursday, November 30, 2023 12:00:00 AM CSTPHONE NUMBER AVAILABLEEffective Date and Time:Expiration Date and Time:Unpaid Balance:Mailing Address:The applicant, spouse, and all household residents 15 years of age or older, all regular operators of the vehicles described in this application, and all children who live away from home who drive these vehicles, even occasionally, are listed below. Contact Information:Mobile: PHONE NUMBER AVAILABLEYour insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown for a vehicle may not be combined with the limits for the same coverage on another vehicle.Name Date of Birth Sex Marital Status Relationship Driver Status CAMERON HARRIS M Single Named Insured Rated 1FAHP3HN0AW277008Garaging Zip Code: 370832010 Ford FOCUS SELVIN:Application for InsurancePlease review and sign where indicated. Policyholder: CAMERON HARRIS May 30, 2023Policy Number: PHONE NUMBER AVAILABLE11 PA TN AP (6/19) Page 1 of 6Subtotal Policy Premium $698.00Total 6 Month Policy Charges $713.00A fully earned installment of $10 per Direct Bill Invoice sent, or $6 per Recurring Credit/Debit Card draft, or $6 per EFT draft will be charged, in addition to the policy charges shown above.Limits Deductible PremiumLiability To OthersBodily Injury $50,000 Per Person/$100,000 Per Occurrence $204.00 Property Damage $50,000 Per Occurrence $391.00Uninsured Motorists Bodily Injury $50,000 Per Person/$100,000 Per Occurrence $47.00 Uninsured Motorists Property Damage $200 $43.00Medical Payments $2,000 Per Person $13.00Total Premium for 2010 Ford FOCUS SEL $698.00Policy Fee $15.00Driver HistoryTrexis uses your driving history to determine your rate. Driver Description Date Source DisputedCAMERON HARRIS Improper Passing Mar 17, 2023 MVRCAMERON HARRIS Minor Oct 27, 2022 MVRCAMERON HARRIS Speeding Jul 30, 2021 MVRCAMERON HARRIS Improper Passing Jun 5, 2020 MVRPrior Insurance and Underwriting QuestionsNo prior insurance selectedApplicant Questionnaire1. Have all the household residents 15 years of age or older, all regular operators of the vehicles described in this application, and all children who live away from home who drive these vehicles, even occasionally, been disclosed in the Drivers and Household Residents section?(If no, please list.)Yes No2. Is the garaging address listed on the application the same for all drivers?(If no, please explain below.)Yes No3. Does any driver listed on the application reside outside the state of Tennessee for more than 2 months per year?(If yes, you are not eligible for this insurance.) Yes No4. Is the garaging address listed on the application correct for all vehicles to be insured on the policy? (If no, please explain below.) Yes No5. Are any of your vehicles used for delivery, limousine or taxi service, for courier or escort service, or for commercial pick up or delivery purposes, including but not limited to delivery of magazines, pizza, food, mail, newspaper or farm produce? Policyholder: CAMERON HARRISMay 30, 2023Policy Number: PHONE NUMBER AVAILABLE11 PA TN AP (6/19) Page 2 of 65.but not limited to delivery of magazines, pizza, food, mail, newspaper or farm produce?(If yes, you are not eligible for this insurance.) Yes No6. Are any listed vehicles used in the course of any driver's business or occupation, other than driving back and forth to work?(If yes, please explain below.)Yes No7. Are there other vehicles in your household not listed on this application?(If yes, please give the vehicle, driver and vehicle insurer.) Yes No8. Are there any listed vehicles with pre-existing damage?(If yes, please explain below.)Yes No9. Have you or any other driver or household resident listed on this application provided transportation services through or registered to provide transportation services through a Transportation Network Company; mobile device-based ridesharing service or other platform within the last three(3) years? (If so, you are not eligible for insurance with Trexis.)Yes NoApplication AgreementVerification of ContentI have read, reviewed and understand my entire application. I hereby declare that the statements, representations and promises made herein are true. I declare that none of the vehicles listed in this application will be used to carry persons or property for compensation or a fee, or for retail or wholesale delivery, including, but not limited to, the pickup, transport, or delivery of magazines, newspapers, mail, or food. I understand that my statements, representations and promises become a part of my contract. I also understand and agree that if I have omitted or provided any information that is false, misleading, inaccurate and/or would affect the Companys decision to accept the risk, provide the limits or coverages requested, or provide the coverages at the premium charged, the Company may, in its sole discretion: reject my application; charge an increased premium for which I will be responsible; or, declare the policy or any renewal policy void from inception. I understand that it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. I acknowledge that this application was fully and completely explained to me by an authorized Trexis agent of my own choosing. Notice of Information PracticesI understand that to calculate an accurate price for my insurance, the Company may obtain information from third parties, such as consumer reporting agencies that provide driving, claims and credit histories. The Company may use a credit-based insurance score based on the information contained in the credit history. The Company or its affiliates may obtain new or updated information to calculate my renewal premium or service my insurance. I may access information about me and correct it if inaccurate. I may request that my credit information be updated or that the Company reevaluate my insurance based on corrected credit information from a consumer reporting agency. In some cases, the law permits the Company to disclose the information it collects without authorization. However, the Company will not share personal information with non-affiliated companies for their marketing purposes without consent. Complete details are in the Companys Privacy Policy, which will be provided with this insurance policy and upon request. I Affirm ThatAll my vehicles insured for Other Than Collision and Collision must be inspected by a representative of Trexis within seven (7) days from the effective date of this policy.If I make my initial payment by electronic funds transfer, check, draft, or other remittance, the coverage afforded under this policy is conditioned on payment to the Company by the financial institution. If a transfer, check, draft, or other remittance is not honored by the financial institution, the Company shall be deemed not to have accepted the payment and this policy shall be void. If I make my initial payment by credit card, the coverage afforded under this policy is conditioned on payment to the Company by the card issuer. I understand that if the Company is unable to collect my initial payment from the card issuer, the Company shall be deemed not to have accepted the payment and this policy shall be void. I also understand that if I authorize a credit card transaction for any payment other than the initial payment, this policy will be subject to cancellation for nonpayment of premium if the Company is unable to collect payment from the card issuer. The Company is deemed unable to collect in the following instances: (1) when I reach my credit limit on my credit card and the card issuer refuses the charge; (2) when the card issuer cancels or revokes my credit card; or (3) when the card issuer does not pay the Company, for any reason whatsoever, upon the Companys request. Agent Compensation DisclosureThe insurance producer that sold you this policy is a licensed insurance agent authorized by Trexis and by other insurance companies to solicit business on their behalf. We will pay your agent a commission for placing your policy with us. Your agent may also be eligible for additional compensation, based upon the volume and profitability of certain business he or she places with us. Policyholder: CAMERON HARRISMay 30, 2023Policy Number: PHONE NUMBER AVAILABLE11 PA TN AP (6/19) Page 3 of 6I represent that I am the person identified as the Named Insured and am listed in the Drivers and Household Residents section of this application. I acknowledge and agree to the statements contained within this application. Applicant SignatureOther ChargesI acknowledge and agree to pay the fees shown on my billing statement that become due during the policy term and each renewal policy term in accordance with the payment plan I have selected. I understand that the amount of these fees may change upon policy renewal or if I change my payment plan. I understand that a Service Charge of $25.00 will be assessed to the balance due on my policy if any check offered in payment is not honored by my bank or other financial institution. Imposition of such charge shall not deem the Company to have accepted the check unconditionally. I understand that a fully earned $15.00 Policy Fee will be charged for each new and renewal policy. Additionally, a fully earned installment fee of $10.00 per Direct Bill invoice sent, or $5.00 per Recurring Credit/Debit Card draft, or $5.00 per EFT draft will be charged. I also understand that, if applicable, my policy may be charged a Reinstatement Fee of $10.00, a Late Fee of $10.00 or a Financial Responsibility Fee of $20.00. I understand that my acknowledgement of a Reinstatement Fee does not obligate the Company to reinstate coverage following a cancellation lapse. I understand that motor vehicle records will be ordered before my policy is issued. If there are additional accidents or violations, they will be charged for and/or this policy may be canceled. I also understand that if the application does not meet the acceptability requirements of the selected program, the policy could be issued at a higher rate.I agree to report any and all claims directly to the Company immediately after they occur. Policyholder: CAMERON HARRISMay 30, 2023Policy Number: PHONE NUMBER AVAILABLE11 PA TN AP (6/19) Page 4 of 6Signature of Named Insured DateXProducer SignatureThe undersigned hereby warrants and certifies that the information contained herein is correct to the best of his/her knowledge; that this application was fully and completely explained to the Named Insured; that this application was completed and then signed by the Named Insured; that a completed copy has been given to the Named Insured; and that the undersigned will retain a copy hereof. Signature of Producer DateXPolicyholder: CAMERON HARRISMay 30, 2023Policy Number: PHONE NUMBER AVAILABLE11 PA TN AP (6/19) Page 5 of 65/30/2023 12:44:38 PMPolicyholder: CAMERON HARRISMay 30, 2023Policy Number: PHONE NUMBER AVAILABLE11 PA TN AP (6/19) Page 6 of 6Due Date Payment05/30/2023 $178.2506/30/2023 $116.9507/30/2023 $116.9508/30/2023 $116.9509/30/2023 $116.9510/30/2023 $116.95*PLEASE NOTE: The payment amounts listed are based on the information provided. Any discrepancies may impact the installment amount shown on this schedule.Payment ScheduleFranklin, TN 37068PHONE NUMBER AVAILABLE PO Box 682322Policy Number: PHONE NUMBER AVAILABLEPolicyholder: CAMERON HARRISMay 30, 2023INSURED CopyAgency Payment Receipt Form Trexis InsuranceCorporationPHONE NUMBER AVAILABLE * P.O. Box 682322Franklin, TN 37068-2322Payment Method CREDIT Credit Card No. xxxxxxxxxxxx5217 The payment indicated below was received in this agency at the date and time indicated. 8936233 Insured's Name CAMERON HARRIS Policy Number PHONE NUMBER AVAILABLE Payment Amount $178.25 Transaction ID:Agency Name TOOLEY & CARVER INSURANCE Agency Code 410499 Agent's Signature Date 5/30/2023 Time 12:42:02 PM CT Down Payment Due With Application (including optional products) Total Premium $174.50Policy Fee $3.75Total Due With ApplicationTotal Amount Paid: $178.25$178.25VIN: 1FAHP3HN0AW277008Trexis Insurance CorporationP.O. Box 682322Franklin, TN 37068-2322PHONE NUMBER AVAILABLEPOLICY NUMBER: PHONE NUMBER AVAILABLEYEAR: 2010 MAKE: Ford MODEL FOCUS SELAGENT: TOOLEY & CARVER INSURANCEPHONE: PHONE NUMBER AVAILABLETHE INSURED SHALL KEEP A COPY OF THE INSURANCE CARD IN EACH MOTOR VEHICLE COVERED BY THE POLICY.VIN: 1FAHP3HN0AW277008Trexis Insurance CorporationP.O. Box 682322Franklin, TN 37068-2322PHONE NUMBER AVAILABLEPHONE NUMBER AVAILABLEYEAR: 2010 MAKE: Ford MODEL FOCUS SELAGENT: TOOLEY & CARVER INSURANCEPHONE: PHONE NUMBER AVAILABLETHE INSURED SHALL KEEP A COPY OF THE INSURANCE CARD IN EACH MOTOR VEHICLE COVERED BY THE POLICY.EFFECTIVE: 5/30/2023 TO: 11/30/2023EFFECTIVE: 5/30/2023 TO: 11/30/2023TENNESSEE IDENTIFICATION CARDTENNESSEE IDENTIFICATION CARDNAIC #: 12188NAIC #: 12188INSURED:INSURED:DRIVER:DRIVER:CAMERON HARRIS305 MAIN STLAFAYETTE, TN 37083CAMERON HARRIS305 MAIN STLAFAYETTE, TN 37083CAMERON HARRISCAMERON HARRISPOLICY NUMBER:ONE CARD MUST BE KEPT IN THE VEHICLEAND PRESENTED UPON REQUESTReport all accidents to The Trexis insurance companies as soon as possible: PHONE NUMBER AVAILABLEIn case of an accident, please obtain the following information: 1) Name, address and phone number ofeach driver, passenger, and witness.2) Name of Insurance Company and policynumber for each driver/vehicle involved.THIS POLICY MEETS THE MINIMUM STATEFINANCIAL RESPONSIBILITY LAW.ONE CARD MUST BE KEPT IN THE VEHICLEAND PRESENTED UPON REQUESTReport all accidents to The Trexis insurance companies as soon as possible: PHONE NUMBER AVAILABLEIn case of an accident, please obtain the following information: 1) Name, address and phone number ofeach driver, passenger, and witness.2) Name of Insurance Company and policynumber for each driver/vehicle involved.THIS POLICY MEETS THE MINIMUM STATEFINANCIAL RESPONSIBILITY LAW.Franklin, TN 37068-2322PHONE NUMBER AVAILABLE * P.O. Box 682322Trexis Insurance CorporationInsurance Identification CardsFranklin, TN 37068-2322PHONE NUMBER AVAILABLE * P.O. Box 682322Trexis Insurance CorporationInsurance Identification CardsTrexis has a long history of protecting the privacy of its customers. This notice describes the personal information we collect about you and how we use and protect it. It applies to our current policyholders who live in your state and replaces any earlier version that we may have provided you.What information is collected?We collect information about you to quote and service your policy. This is typically called Nonpublic Personal Information if it identifies you and is not available to the public. Depending on the product, we collect it from some or all of the following sources. Not all examples may apply specifically to your policy. Application Information You provide this on your application through your agent. We also obtain it from other directories or outside sources. It includes your name, street and email addresses, phone numbers, drivers license numbers, social security numbers, date of birth, gender, marital status, types of vehicle, and information about other drivers.Consumer Report Information We obtain this from consumer reporting agencies. It includes your driving record, claims history with other carriers, and credit report information. The information is kept by the consumer reporting agencies and disclosed to them by others only as permitted by law.Transaction Information This includes your insurance coverages, policy limits, and payment and claims history. It also includes information that we require for billing and payment.Website Information This information is unique to internet transactions. It includes the pages you view on our site, and your computer operating system. Some websites, including ours, may store cookies on your computer. Cookies collect technical data like your IP address, operating system, and session ID. They can also save certain information entered by you. Some of our websites contain specific privacy notices. Please read these when using those sites.How is information shared?We will share information about you only as permitted by law. We will not share your Nonpublic Personal Information with other companies for their marketing purposes without your consent. There is no need to opt out or tell us not to do this. Disclosures include those we feel are required to provide insurance claims or customer service, prevent fraud, perform research, or comply with the law. Recipients include, for example, claims representatives, service providers, and consumer reporting agencies, insurance agents, law enforcement, courts and government agencies. These parties may disclose this information to others as permitted by law. For example, consumer reporting agencies may disclose transaction information received from us to other insurance companies with which you do business. How can information be reviewed and corrected?To review information we have about you, send a written request to Trexis Customer Service, PO Box 682322 Franklin, TN 37068. You must describe the information you wish to review and state that your request is in response to this Privacy Policy. Include your full name, mailing address, and policy or claim number (if applicable). Within 30 business days, we will describe what is available and how you may request corrections. We will also name anyone we show as having received the information within two years of your request. Finally, we will identify the companies that have provided consumer report information about you. We will not provide information we feel is privileged, such as information about insurance claims or lawsuits. To correct information about you, send a written request detailing your desired correction. Within 30 business days, we will either make the requested correction or tell you why we cannot. We cannot correct consumer report information, such as your credit report. To do this, you must contact the consumer reporting agency that provided it. If we make your requested correction, we will notify you in writing. We will also notify anyone named by you who may have received the information within the previous two years. If required by law, we will also notify others who may have given it to or received it from us. If we refuse to make the requested correction, you may file with us a statement detailing why you object, including the information you think is correct. Your statement will then become part of your file. It will be sent to the same group that we would send a copy of any correction or change. Our family of insurance companiesThis notice is from our family of insurance companies. As of the date of this Privacy Policy, this includes: Trexis One Insurance Corporation and Trexis Insurance Corporation.Privacy Policy |
