CHICAGO, IL 60638

POLICY NUMBER: MOV 619219-00

Missouri Maverick Auto
Program DATE PROCESSED: 011/01/2020

P. O. BOX 389508
POLICY PER
COVERAGE PROVIDED IN THE PERSONAL CAR POLICY DECLARATIONS This policy was bound on 0
This declarations is subject to all of the terms and conditions of the Policy and shall continue in PM
force for the period shown provided the required premium is paid.
EFFECTIVE:11 01 20 EXPIRATION: 05 01 21
 VEHICLE(S)

TO VEHICLE SURCHARGE BUS C CO M MAKE/MO

T I O M O D
A N LL P D EL
V
ST CL TE L E S SY S A EL /B
E LOSS PAYEE / ADDITIONAL INTEREST
AT AS R P S Y M Y G Y O
L H
E S R T VEHICLE # / PROPERTY TYPE S M
LIENHOLDER ME E D
#
S U A Y
DRIVERS S R TY
E PE

NAMED INSURED(S)/CONTENTS PLUS ENDORSEMENT

MARITAL / CU DRIVER'S LICENSE
DRV # NAME DOB AGE SEX POINTS
STATUS LICENSE # STATE
1 JEFFERY SEAT 12/02/1961 58 S M W167349003 MO 0
JEFFERY SEAT
CURRENT COVERAGES*
802 N JEFFERSON ST
1 MO *Subject to all of the terms and conditions of the applicable Policy/Endorsements
SPRINGFIELD, MO 65802
56SF COVERAGES LIMITS OF LIABILITY 14 14 Veh141 12
13.0 0
Bodily Injury Liability $ 25,000 per person/ $ 50,000 per accident $ 139
Property Damage Liability $ 25,000 per accident $ 150
Uninsured Motorists/ Underinsured Motorists - BI $ 25,000 per person / $ 50,000 per accident $ 50
VEHICLE TOTALS $ 339
0 POLICY:
FORMS AND ENDORSEMENTS MADE PART OF THIS
FCMOMV01030719, FCMOMV62010719, FCMOMV27030719, FCMSMP09010116 TOT

DISCOUNTS SURCHARGES AND OPTIONS COVERAGES APPLIED: TOTAL PO

Good Driving Record Discount,Liability Only Discount
17-00 20

RIOD
02 2021 12:01 AM
11/01/2020 at 04:20

Y
VEHICLE IDENTIFICATION

4A3AC84H32E036777

LOAN NUMBER

SURCHARGE STATUS

0 Rated
 TAL PREMIUMS $ 339
POLICY FEES $ 12
TOTAL FEES $ 12
OLICY PREMIUM $ 351
FCMSMP05020119
 AMENDMENT OF POLICY PROVISIONS - MISSOURI
This endorsement amends the policy to which it is attached and made part of same by hereby replacing, adding and/or deleting the
following
language:
DEFINITIONS
The following definition is being DELETED in its entirety:
Hit-and-run motor vehicle means a vehicle that causes bodily
injury to an insured person or property damage to an owned
auto arising out of direct physical contact of such vehicle with the
insured person or with a motor vehicle that the insured person
is occupying at the time of the accident, provided the identity of
neither the operator nor the owner of the hit-and-run motor
vehicle can be ascertained. The insured person must undertake
reasonable efforts to ascertain the identity of the operator or owner
of the hit-and-run motor vehicle.
The following definition is being MODIFIED:
Uninsured motor vehicle means a vehicle or trailer with respect
to which there is:
(a) no bodily injury liability insurance policy, bond or other
security applicable at the time of the accident; or
(b) a bodily injury liability insurance policy, bond or other security
that is less than the minimum amount set forth in section
303.030 (or its successors) of the Missouri Vehicle Code; or
(c) a bodily injury liability insurance policy, bond or other security
applicable at the time of the accident but the bonding or
insuring company writing the same is or becomes insolvent
subsequent to the date of the accident; or
(d) which is a hit-and-run motor vehicle whose operator or owner
cannot be identified and which hits or causes an auto accident
resulting in bodily injury to:
(1) you or a relative;
(2) a motor vehicle you or any relative are occupying; or
(3) your insured auto.
If there is no physical contact with the hit-and-run vehicle, the
facts of the accident must be proved. We may request
supporting evidence other than the testimony of a person
making a claim under this or any similar coverage to support
the validity of the such claim.
But the term uninsured motor vehicle shall not include a vehicle
or trailer:
(a) owned by or furnished or available for the regular use of any
insured person or any relative or person residing in your
household;
(b) owned by any government or quasi-governmental unit or
agency;
(c) operated on rails or crawler treads; or
(d) that is a farm type tractor or other conveyance or implement
designed mainly for use off public roads while not upon public
roads;
(e) while located for use as a residence or premises; or
(f) owned or operated by a self-insurer within the meaning of any
financial responsibility law, motor carrier law or any similar law
except a self-insurer that is or becomes insolvent.
(g) vehicles with four wheels or less designed primarily for off road
use.
PART I - LIABILITY
The following is ADDED to the Definitions under Part I - Liability
Coverages A & B:
FCMOMV62010719 Page 1 of 4
NOTE: An owned auto and attached trailer are considered
one vehicle, and a temporary substitute auto and attached
trailer are considered one vehicle. Therefore, the limits of
liability will not be increased for an accident
involving an owned auto or temporary substitute auto, which
has
an attached trailer.
The following is added to the EXCLUSIONS under Part I - Liability
Coverages A & B:
(w) to bodily injury or property damage resulting from the
ownership, maintenance or use of any motorized vehicle with
more or less than four wheels;
(x) to bodily injury or property damage arising out of the use of
an insured auto while leased or rented to others. This
exclusion does not apply to the operation of an insured auto
by you or a relative;
If a court with proper jurisdiction determines an exclusion is invalid
or unenforceable because it does not satisfy the requirements of
the Missouri Motor Vehicle Responsibility Law, the exclusion will
apply only to that portion of the damages that is in excess of the
minimum limits of liability required by law.
The following is ADDED to OTHER INSURANCE under Part I -
Liability Coverages A & B:
No insured person will be entitled to receive duplicate payments
under Parts II, III, or V of this policy.
OUT OF STATE COVERAGE
If an auto accident to which this policy applies occurs in any
state other than the one in which this the insured auto(s) is
principally garaged, we will interpret your policy for that accident
as follows:
If the state or province has a compulsory insurance or similar law
requiring a nonresident to maintain insurance whenever the
nonresident uses a vehicle in that state or province, your policy
will provide at least the required minimum amounts for bodily
injury or property damage as specified by that state or province.
Except as provided by the above, no other coverage afforded by
this policy shall be modified.
PART II - UNINSURED MOTORIST COVERAGE
The following REPLACES, in its entirety, the Insuring Agreement
under Part II - Uninsured Motorist Coverage Coverages C & D:
This coverage is only applicable if premium has been paid for the
coverage and shown on the Declarations. We will pay all sums,
but only to the extent of applicable policy limits, that the insured
person shall be legally entitled to recover as damages from the
owner or operator of an uninsured motor vehicle because of
property damage to an insured auto or bodily injury sustained
by the insured person, caused by an accident and arising out of
the ownership, maintenance or use of such uninsured motor
vehicle; provided, for the purposes of this coverage,
determination as to whether the insured person is legally entitled
to recover such damages and, if so, the amount thereof, shall be
made by agreement between the insured person and us.
Recovery under this Part for property damage is subject to the
payment of a specific separate premium for uninsured motorist
property damage.
 No judgment against any person or organization alleged to be
legally responsible for bodily injury shall apply to us or be
conclusive between the insured person
and us as to the issues of liability of such person or organization or
as to the amount of damages to which the insured person is
legally entitled.
The following is ADDED to the Exclusions under Part II - Uninsured
Motorist Coverage Coverages C & D:
(o) other than compensatory damages for death and bodily injury
to make an injured party whole within the limitations of this
policy, any additional damages, costs, expenses, attorney's
fees, fines, penalties, treble damages, punitive damages or
smart money which may be recoverable or awarded at law or in
equity as a consequence of reckless driving, operating a motor
vehicle with a blood or breath of alcohol content deemed to be
legally intoxicated, causing or contributing to operating a motor
vehicle while intoxicated; or reckless endangerment.
The ARBITRATION section is DELETED, in its entirety, from Part II
Uninsured Motorist Coverage Coverages C & D.
PART IV - MEDICAL PAYMENTS
The following is ADDED to the Definitions under Part IV - Medical
Payments Coverage F:
Usual and customary charge means an amount which we
determine represents a customary charge for services in the
geographical area in which the service is rendered. We shall
determine the usual and customary charge through the use of
independent sources of our choice.
The following is ADDED to the Exclusions under Part IV - Medical
Payments Coverage F:
(r) bodily injury sustained by an insured person while a
passenger in a taxi, limousine or other public or livery
conveyance which is not owned, rented or leased for use by
you or a relative;
(s) to bodily injury sustained by any person while occupying an
insured auto without the express or implied permission of you
or a relative.
The following is MODIFIED in OTHER INSURANCE under Part III
Medical Payments Coverage F:
(b) This policy does not apply under Part II to bodily injury to the
extent that any medical expenses is paid or payable to or on
behalf of the injured person under the provisions of any:
(1) premises insurance affording benefits for medical expenses;
(2) accident or disability insurance; or
(3) medical, hospital or surgical insurance; or
(4) motor vehicle medical payment insurance.
The following is DELETED, in its entirety, from the Limits of Liability
under Part IV - Medical Payments Coverage F:
(d) Any amounts payable under this coverage Part IV will be
reduced by any amounts paid or payable for the same elements of
loss under
Parts I, II, or III of this policy.
PART VI - PHYSICAL DAMAGE TO YOUR AUTO
The following is ADDED to the DEFINITIONS under Part VI -
Physical Damage to Your Auto Coverage G & H:
Special Equipment, when it appears in this Part, means: Any non-
factory installed equipment permanently attached to the interior or
exterior of an insured auto. Special Equipment shall include but
is not
FCMOMV62010719 Page 2 of 4
limited to custom paint work, special antennas, customized
windows or window treatments, non-factory installed sound
systems, custom wheels running boards or any other equipment
which mechanically or structurally changes the appearance or
performance of the vehicle.
The following is ADDED to the LOSS SETTLEMENT UNDER
COVERAGE G & H under Part VI - Physical Damage to Your Auto
Coverage G & H:
(f) If we repair or replace damaged or stolen property, we reserve
the right to use parts of like kind and quality or after-market
parts at our option.
The following is ADDED to the EXCLUSIONS under Part VI -
Physical Damage to Your Auto Coverage G, H, I, & J:
(s) to loss to an insured auto caused directly or indirectly by mold,
mildew, or fungus, including but not limited to any type or form
of;
(1) decomposing or disintegrating organic material or
microorganism or
(2) organic surface growth on moist, damp, or decaying matter; or
(3) yeast or spore-bearing plant-like organism; or
(4) spores, scents, toxins, bacteria, viruses or any other by-
products produced or released by any mold, mildew,
fungus or other microbes However, this exclusion does not
apply to loss caused by mold, mildew, or fungus, if such loss is
a result of any other covered loss under this Part V.
(t) We will not pay for loss to any of the following special
equipment;
(1) any caddy, case or container designed for use in carrying or
storing stereo tapes, cassettes, compact discs, mp3's or any
othe electronic media; or
(2) any special antennas designed to be used with any radio or two
way communication device; or
(3) any bubble-dome, bubble window or customized roof treatment;
and
(4) any custom paint work, decals or custom tape striping; or
(5) any equipment or accessories which change the use or
appearance of the interior of the insured auto; or
(6) any chrome, reverse chrome, alloy or magnesium wheels,
chrome engine accessories, racing slicks, or non-factory
installed tachometer or pressure gauges; or
(7) any non-factory installed equipment which mechanically or
structurally changes the automobile and results in an increase
in performance or change the appearance; or
(8) any non-factory installed auto speakers not designed to be
housed in the original manufacturer's location; or
(9) any T-Bar roof;
unless said equipment is specifically listed in the policy
declarations
and a special equipment premium is charged.
POLICY CONDITIONS
The following REPLACES, in its entirety, 4:
4. Fraud, Misrepresentations and Omissions
(a) We do not provide coverage for any person who has made
fraudulen statements or engaged in fraudulent conduct in
connection with any accident or loss for which coverage is
sought under this policy.
(b) We do not provide coverage for any person if you (or anyone
on your behalf) made fraudulent statements or misrepresented
or
concealed anything material in the presentation of your
application for insurance.
(c) If you (or anyone on your behalf) made fraudulent statements,
material misrepresentations or omitted any material fact in your
application for this policy then you shall repay us for any
payments or costs we incur as a result of providing coverage
based upon such fraudulent statements, material
misrepresentations, or omitted material fact. Costs include (but
are not limited to) attorney fees, settlement payments,
investigation fees and reports, postage, copying charges,
deposition fees, mileage and fees for experts.
(d) If you or any person seeking coverage under this policy make
any fraudulent statements or engage in fraudulent conduct in
connection with any accident or loss for which coverage is
sought under this policy and your state restricts our right to
rescind all or any portion of this policy, then you shall repay us
for any payments or costs we incur associated with such
payments that we would not have had to make if our right to
rescind was not limited. Costs include (but are not limited to)
attorney fees, settlement payments, investigation fees and
reports, postage, copying charges, deposition fees, mileage,
and fees for experts.
(e) If a Compulsory Insurance Law requires us to make payments
that would otherwise be excluded from coverage under PART I
- LIABILITY COVERAGES A & B of this policy, then you shall
repay us for any such payments or costs we incur associated
with such payments that we would not have otherwise had to
make. In the event we are required to make any payment, our
obligation shall be limited to those coverages or benefits the
law restricts us from rescinding. Our obligations will not include
any other coverage or benefit that the applicable law does not
restrict us from rescinding.
(f) If, at any time, we become aware of a misrepresentation which
would have made the risk ineligible or resulted in a higher
premium charge, we reserve the right to retroactively endorse
your policy to the correct premium charge. In the event that we
exercise that right, you will be liable for the total premium
amount charged for your coverage, which shall include any
additional premium amounts you would have been charged for
that coverage had such misrepresentations not been made.
(g) Nothing in this Condition shall preclude us from exercising or
pursuing any other right or remedy available under Missouri
law.
The following REPLACES, in its entirety, 5:
5. Cancellation or Non-renewal of this
Policy (a) By you:
You may cancel this policy by surrendering it to us or to
any of our authorized agents, or by mailing advance written
notice to us stating when the cancellation is to be effective.
(b) By us:
(1) We may cancel by mailing to the named insured shown in the
Declarations at the address last known by us a written notice
which states the reason for cancellation and provides:
(a) at least 10 days notice if cancellation is for nonpayment of
premium; or
(b) at least 30 days' notice by in all other cases.
(2) After this policy has been in effect for 60 days, or if this is a
renewal or continuation policy, we will cancel only by mailing a
notice which provides for one of the following reasons:
(a) nonpayment of premium; or
FCMOMV62010719 Page 3 of 4
(b) your driver's license has been suspended or revoked.
This must have occurred:
(i) during the policy period; or
(ii) since the last anniversary of the original effective date if the
policy period is other than 1 year.
However, in the event more than one person is a named
insured shown in the Declarations and only one person's
driver's license has been suspended or revoked, we:
(i) may not cancel this policy; but
(ii) may issue an exclusion providing that coverage
will not be afforded to that named person under
the terms of this policy while that person is
operating your insured auto during any period
of suspension or revocation.
(3) Non-renewal: We may decide not to renew or continue this
policy by providing written notice which includes the reason for
nonrenewal to the named insured shown in the declarations at
the last address known by us. Notice will be mailed at least 30
days prior to the end of the current policy period.
(4) Automatic Termination:
(a) If we offer to renew or continue coverage and you or your
representatives do not accept, this policy will automatically
terminate at the end of the current policy period. Failure to pa
the required renewal or continuation premium when due shall
mean that you have not accepted our offer.
(b) If you obtain other insurance on your insured auto, any similar
insurance provided by this policy will terminate as to that auto
on the effective date of the other insurance.
(c) If someone other than you or a relative who is listed on the
declarations becomes the owner of an insured auto, coverag
for that insured auto will automatically terminate. The
termination will correspond with the time that possession or ti is
conveyed to the new owner.
(5) Other Termination Provisions:
(a) Proof of mailing of any notice shall be sufficient proof of notic
(b) If you cancel this policy, the premium refunded shall be
computed on a pro rata basis. If we cancel this policy, any
premium refund owed shall be calculated pro-rata. Making or
offering to make such a refund is not a condition of cancellation;
(c) The effective date of cancellation on the notice shall become
the end of the policy period.
The following REPLACES, in its entirety, 8(a):
(a) As soon as practicable, you or your legal representative shall
provid notice to us of any loss or accident involving an
insured person or insured auto with respect to which this
policy may apply, but in no
case later than 30 days; however, no claim will be denied based
upo the insured's failure to provide notice within such specified
time, unless this failure operates to prejudice the rights of the
insurer, as p Missouri regulation 20CSR100-1.020.
The following REPLACES, in its entirety, 8(d):
(d) In the event an insured person or insured auto is involved in
an incident with a hit-and-run motor vehicle, and insured
person shall report the incident to the police department with
jurisdiction over the place where the incident took place within
24 hours of discovering th accident. The insured person shall
report the incident to us within 3 days of the date of the
incident; however, no claim will be denied based upon the
insured's failure to provide notice within such specifie time,
 unless this failure operates to prejudice the rights of the insurer
as per Missouri regulation 20CSR100-1.020.
The following REPLACES, in its entirety, 19:

19. Legal Actions/Time Limitations

Part I. No action will lie against us unless the insured person has
first complied with all the terms of this policy, nor until the amount
of damage an insured person is legally liable to pay has been
determined either b judgment against the insured person after
actual trial or by written agreement of the insured person, the
claimant and us. Any lawsuit sha be filed within ten years after the
expiration date of the policy term effective at the time of the date of
loss. No person or organization has an right under this policy to join
us as a party to any action against an insured person to
determine his or her liability, nor will we be impeded by an insured
person's or the insured person's legal representative. Bankruptcy
or insolvency of the insured person does not release us fro our
obligations under this policy. Part II and Part III. No action will lie
against us unless there has first been full compliance with all of the
term of this policy and such action is
commenced within ten years after the expiration date of
the policy term effective at the time of the date of loss.
Part IV. No action shall lie against us unless;
(a) there has been full compliance with the terms of this policy;
(b) at least 30 days have expired since the filing of a proof of
loss;
(c) the amount of the loss has been determined as provided in
this policy; and
(d) the lawsuit must be filed within ten years after the expiration
date of the policy term effective at the time of the date of loss.

The following is ADDED to 25. Complaints and Grievances:

(b) If you feel that our response is insufficient, you may also send
grievances to:
Missouri Department of Insurance, Financial Institutions &
Professional Registration
PO Box 690
Jefferson City, MO 65102-0690.

The following is ADDED:

24. Missouri Property and Casualty Insurance Guaranty

Association Coverage Limitations
Subject to the provisions of the Missouri Property and
Casualty Insurance Guaranty Association Act (to be
referred to as the Act), if we are a member of the
Missouri Property and Casualty Guaranty Association (to
be referred to as the Association), the Association will
pay claims covered under the Act if we become
insolvent. Payments made by the Association for
covered claims will include only that amount of each
claim which is less than $300,000. However, the
Association will not pay an amount in excess of the
applicable limit of liability of the policy from which a claim
arises. The claims covered by the liability of the policy
from which a claim arises. The claims covered by the
Association are subject to the limitations of the coverage
provided by the Act. These limitations have no effect on
the coverage we will provide under this policy.

FCMOMV62010719 Page 4 of 4
 INSUREONLINE.COM
AUTOMOBILE APPLICATION Producer Name:
Address: 6640 S CICERO AVE
Missouri Maverick Auto Program City, State, ZIP: BEDFORD PARK, IL 60623
P. O. BOX 389508•CHICAGO, IL 60638 Phone Number: (708) 730-6000
708-552-4400
Producer Code: 4510766
POLICY INFORMATION PRIOR INSURANCE INFORMATION
Effective Date: 11/01/20 Time: 04:20 PM Company NO PRIOR
Expiration Date: 05/01/20 Time: 12:01 AM Expiration Date Policy Term: 6 Policy Number:
MOV 619219-00 Policy Number
Coverage is bound no earlier than 04:20PM the date received by Company (premium or deposit must be enclosed) unless prior arrangements are made with Company.
APPLICANT INFORMATION AUTO/GARAGE INFORMATION (If different from mailing address) Name Insured:
JEFFERY L SEAT Address: 802 N JEFFERSON ST
Mailing Address: 802 N JEFFERSON ST Unit #: City, State, ZIP:
City, State, ZIP: SPRINGFIELD, MO 65802 CONTENTS PLUS RENTERS ENDORSEMENT INFORMATION
Home Phone: (417) 522-9128 (If information is different from mailing address)
Work Phone: | Cell Phone: Address:
Email Address: jeffreyseat@gmail.com City, State, ZIP:
DRIVER(S) Applicant warrants that: 1) All drivers in the household over the age of 15 have been listed on
this application and 2) All possible drivers even those that mayirregular or infrequent basis have been listed on this

application. Applicant understands that failure to list operate the applicant's vehicle(s) on an Initials JS all drivers

and household members is a material misrepresentation of the policy contract.

Marital Social % SR Occurrence

Name DOB Sex Status Relation License # ST Security # Points Use 22 Case # Date
JEFFERY L SEAT 012/02/1961 M S INSURED W167349003 MO 0 N
EMPLOYMENT
Name Employer Street City ST ZIP Occupation
JEFFERY L RETIRED SPRINGFIELD MO 65802 RETIRED
SEAT
VIOLATIONS / LOSSES / CONVICTIONS / SUSPENSIONS / REVOCATIONS
Drv # Date Description Name Street City ST ZIP

VEHICLE(S) (OWNED OR LEASED) Veh 1 DISCOUNTS

Comp $ 139 Good Driving Record Discount,
Yr. Make/Model/Style VIN Liability Only Discount
4A3AC84H32E036777 Sym $ 150
2002 MITSUBISHI/
$ 50 $
14 339
ECLIPSE/GT

Policy Fee $ 12.00 PAYMENT METHOD

LIEN-HOLDER(S)/ADDITIONAL INTEREST
Vehicle/Property
COVERAGES
Bodily Injury Liability
Property Damage Liability
Uninsured Motorists - BI
Drv # Date
Description
Total Premium $ 351.00 Direct Bill: Down Pay & Add'l 5
Payments
LIMITS OF LIABILITY
$ 25,000 per person / $
50,000 per accident
$ 25,000 per accident
$ 25,000 per person / $
50,000 per accident
VEHICLE TOTALS

Coll Air Anti Anti

Sym Cyl Bags Lock Theft T-Top Turbo 4WD Usage
ACV Ter Class
14 Y N N X Basic
5758 13 56SF
 FCMOMV27030719

Name Insured: JEFFERY L SEAT Policy Number: MOV 619219-00

Underwriting Questions
Explain all "Yes" responses in remarks section
1.) Are any driver(s) not properly licensed? (If "Yes" explain) YES NO X

2.) Have any possible drivers, even those that may operate your vehicle on an irregular or infrequent basis, NOT beenlisted on this
application or in the Remarks section? YES NO X

3.) Has any driver been convicted of a motor vehicle felony, manslaughter or reckless homicide, or had licensecancelled, suspended or
revoked? (If "Yes" explain) YES NO X

4.) Is any household resident over the age of 15 not listed on this application or in the Remarks section? (This alsoincludes youthful
operators who are resident students at school.) YES NO X

5.) Has any married insured not listed their spouse on the driver section of the policy or excluded the spouse with asigned endorsement.
(If "Yes" explain) YES NO X

6.) Is any vehicle used for business? (If "Yes", please explain and list all employees.) YES NO X

7.) Does any vehicle have any existing physical damage, including glass breakage? (If "Yes" explain) YES NO X

8.) Are any vehicles located at an address different from the garaging address listed on the application? (If "Yes"explain) YES NO
X

9.) Does any vehicle have special equipment i.e. special paint, sound system or other customizations? (If "Yes"explain) YES NO
X

10.) Do you own any other vehicles not listed on this application? (If "Yes" explain) YES NO X

11.) Is any vehicle not solely titled to applicant's name? Any co-owner and/or co-signer must be disclosed. (If "Yes"explain) YES NO
X

12.) Have any accidents or moving violations for any drivers, including those involving a parked car or hit and run, in thepast 3 years NOT
been listed on the application? YES NO X

Does any driver have, or in the past 3 years, has any driver been treated for a physical or mental condition that
13.) might affect the driver's ability to safely operate a motor vehicle? If "Yes", submit a complete Medical YES NO X Authorization/Physician’s
report. We do not discriminate against qualified drivers with disabilities.
14.) Has any vehicle been modified? (If "Yes" explain) YES NO X

Is any vehicle used as a public or livery conveyance, including any use of the vehicle in conjunction with any transportation
network applications or companies (TNC) or as they are sometimes also known as rideshare
15.) applications or companies, pertaining exclusively to the transportation of individuals for a fee? (If yes, list the YES NO X average
verifiable hours worked per week over the past 90 days.) ( ) 18 hours or less ( ) More than 18 hours
15a.) If "Yes", are you also applying for the TNC Endorsement? YES NO X

16.) Is any vehicle used as a public or livery conveyance pertaining to any form of livery including but not limited toproducts, documents,
newspapers, or food? YES NO X

16a.) If "Yes", are you also applying for the Individual Delivery Coverage Endorsement? YES NO X

17.) Are you also applying for Contents PLUS Renters Endorsement? YES NO X

17a.) If applying for Contents PLUS Renters Endorsement, have there been any losses in the past 3 years (regardless ofany applicable insurance
coverage)? (If "Yes" explain listing lost date, loss cause and amount) YES NO X

17b.) If applying for Contents PLUS Renters endorsement, have you been charged with or convicted of the crime of arsonin the last 5 years? YES NO
X

REMARKS

I/We warrant that I/We have read and understand all of the questions asked, and have answered them truthfully to the best of my ability.
I/We understand that any misleading of false answers to these questions could jeopardize the coverage afforded in this policy.

Applicant's Signature X Date

FCMOMV27030719

This policy provides only the minimum financial responsibility limits for Uninsured Motorist Bodily Injury of $25,000 per person/$50,000
per accident as required by section 303.030 in the MO Vehicle Code.

Statement of No Commercial Use

I/We hereby certify that the vehicle(s) listed on this application for insurance are not used for any commercial or business purposes
unless properly identified on the application and rated with appropriate surcharge on the Declarations page. I/We will not use my
vehicle(s) in the course of my employment or while I/We am self-employed. Business use includes the use of those operators who
visit multiple work sites during one day, do not travel to the same site each date or those whose occupations require working at more
than one job site for a period of time and then working at a different site for another period of time. Said usage includes, but is not
limited to, operation of a vehicle while it is being used as a public or livery conveyance, including any use of the vehicle, whether or
not passengers are present in the vehicle, in conjunction with any transportation network applications or companies, or as they
sometimes refer to themselves, rideshare applications or companies. Examples of these include, but are not limited to, Uber, Lyft, and
Side Car. Usage also includes operation of any vehicle to transport individuals, packages, mailings, deliveries, products, envelopes,
food, or other tangible items. A Home Health Care worker traveling to more than two patient's homes per day must be rated for
business.
I/We understand that use of said vehicles for any commercial or business purposes could be a violation of the terms and conditions of
this policy and jeopardize my coverage.

Applicant's Signature X Date

I/We hereby apply to the company for a policy of insurance as set forth in this application on the basis of statements contained herein.
I agree if such information is false, or misleading or would materially affect acceptance of the risk by Company, or if my check is
returned to the Company for insufficient funds, or if my premium remittance is not honored by the bank, that such policy will be null
and void and no coverage shall be afforded. I understand a routine inquiry may be made which will provide applicable information
concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as
to the nature and scope of the report, if one is made, will be provided. I hereby authorize the company to obtain from the state a copy
of Motor Vehicle Reports for use in rating and/or underwriting the insurance for which I do hereby apply, and any renewal thereof, I
certify that I am authorized to permit the company to obtain Motor Vehicle Reports on all drivers listed herein.
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 resulting additional premium.

Applicant's Signature X Date

The undersigned hereby warrants and certifies that to the best of his/her knowledge all information contained herein is correct; the
statements herein are those of the applicant who has signed this application in my presence, and that the applicant and the
undersigned are retaining a duplicate signed copy hereof. I am legally qualified to submit this application on behalf of the applicant.

Producer's Signature X Date Time

The undersigned on behalf of all insureds, wishes to assist the Company in reducing the environmental and financial costs involved in
providing paper copies of general policy forms. By signing below, the undersigned agrees that the policy and endorsement forms
available from the Company website at www.FirstChicagoInsurance.com and referenced in the declarations page provided by the
Company shall be incorporated in and form an integral part of the insurance policy. The undersigned acknowledges that the Company
will not mail paper copies of the forms available in electronic format, unless the undersigned specifically so requests by calling (708)
552-4400. Paper copies will be provided at no charge.

Applicant's Signature X Date

FCMOMV27030719

VEHICLE DESCRIPTION
YEAR MAKE/MODEL VEHICLE IDENTIFICATION
MISSOURI INSURANCE CARD NUMBER
2002 MITSUBISHI ECLIPSE GT/
Company: Producers: 4A3AC84H32E036777
FIRST CHICAGO INSURANCE COMPANY INSUREONLINE.COM
6640 S. CICERO (708) 730-6000
POLICY EXCLUSIONS CAREFULLY. THIS FORM
BEDFORD PARK, IL 60638 Producer Code: 4510766
DOES NOT CONSTITUTE ANY PART OF
NAIC # 13587
YOUR INSURANCE POLICY.

NAME OF INSURED: JEFFERY SEAT THIS CARD MUST BE CARRIED IN THE INSURED MOTOR
VEHICLE FOR PRODUCTION UPON DEMAND

POLICY NUMBER EFFECTIVE DATE- EXPIRATION DATE IN CASE OF ACCIDENT

MOV 619219-00 11/01/2020 05/01/2021 1. File a report with the police.
2. Express no opinion relative to responsibility and/or liability for FCMOMV03011016
the accident.
3. Exchange insurance information with other driver(s) involved.
4. It is imperative to obtain the names, addresses and telephone
numbers of any and all witnesses.
5. Protect the vehicle from the possibility of incurring further
damage if unable to drive from the scene.
6 Use your cell phone to take as many photos as possible of
the accident scene and of the damaged property/vehicles.
7. Report accidents involving property damage and/or personal
injury to our representative at (708) 552-4400 or (888) 264-
5677.
8. Submit a completed written accident/loss report (enclosed with
your policy) within 72 hours of the accident date.

PRIVACY NOTICE

This notice is being provided for informational purposes and requires no additional action from you.

We value our business relationship in serving you for your important insurance needs. First Chicago Insurance
Company recognizes your confidentiality expectations and is committed to protecting your right to privacy of any non-
public personal information collected before, during, and after you have concluded your business relationship with the
Company. Since we value our business relationship with you, we do not sell customer information or share it with non-
affiliated organizations outside of First Chicago Insurance Company for any marketing purposes. Instead, it is the policy
of First Chicago Insurance Company and its representatives to:

• Collect only information that is necessary or relevant to our business.

• Make a reasonable effort to ensure that information that we act upon is accurate, relevant, timely and complete.
• Use only legitimate means to collect information.
• Make personal information available externally only to respond to legitimate business needs, to regulatory or other
government authorities or as otherwise permitted by law.
• Limit employee access to those of need who are trained in the proper handling of personal information.

We are providing you with the following summary of the kinds of information that First Chicago Insurance Company
may collect, what is done with information after it is collected, and how you can find out about such information, if any,
we have about you in our records.

What kind of information do we collect about you and from whom?

We receive the majority of information directly from you. The policy application form that you complete, as well as any
additional information you provide, generally provides the information that we need to serve your insurance needs. On
occasion, you may be contacted by one of our representatives or affiliates by mail, telephone, and other electronic
means or in person to secure additional information. Depending on the nature of the transaction, additional information
may be secured from outside sources, such as motor vehicle records, loss information reports, credit reports, court
records or other public records. Third parties, such as other insurance companies or investigative consumer reporting
agencies may also provide information. An investigative consumer report may gather information through telephone or
personal interviews with your neighbors, friends, associates, acquaintances, or others who may have knowledge
concerning those items of information. If we order any kind of consumer report, we will notify you and, under applicable
State laws and the Federal Fair Credit Reporting Act, you may have the right to request a personal interview. Upon
written request, we will give you or tell you how to obtain a copy of the report. The agency preparing a consumer report
for First Chicago Insurance Company may keep the information collected about you as permitted by law.

What do we do with the information collected about you?

Information that has been collected about you and retained will be contained in either the Company's policy records or
in your agent's files. The information is reviewed to evaluate your request for insurance coverage and in determining
your premium rates. We will also refer to and use information contained in our policy records for purposes related to
issuing and servicing insurance policies and claims. Your agent may also use information about you in his/her agency
files for insurance marketing purposes or to help you with your overall insurance program. If coverage is declined or the
charge for coverage is increased because of information contained in a consumer report we obtained, we will tell you
 as required by applicable State law and the Federal Fair Credit Reporting Act. We will also give you the name and
address of the consumer-reporting agency issuing the report.

To whom do we disclose information about you?

• Your agent or broker.

• Parties who perform a business, professional or insurance function for our Company, including our affiliated companies
and reinsurance companies.
• Independent claims adjusters, appraisers, investigators and attorneys who require the information to investigate, defend
or settle a claim involving you.
• Businesses that assist us with data processing.
• Businesses that conduct scientific research, including actuarial or underwriting studies.
• Other insurance companies, agents or consumer reporting agencies as reasonably necessary in connection with any
application, policy, or claim involving you.
• Insurance support organizations that are established to collect information for the purpose of detecting and/or preventing
insurance crimes or fraudulent claims.
• Medical care institutions or medical professionals to verify coverage or conduct an audit of services.
• Insurance regulatory agencies in connection with the regulation of our business.
• Law enforcement or other governmental authorities to protect our legal interest or in cases of suspected fraud or
illegal activities.
FCMSMP09010116 Page 1 of 2

• Authorized persons as ordered by a subpoena, warrant or other court order or as required by law.
• Certificate holders or policyholders for the purpose of providing information regarding the status of an insurance
transaction.
• Lienholders, lessors or other persons or organizations shown in our records as having a legal interest or beneficial
interest in your policy.

We do not provide information about you, such as your name and address, to persons or organizations that may wish
to provide you with information about their non-insurance products or services.

Should you cease to be a policyholder of the Company, or after your claim is settled, the Company's policy is to archive
your information for a period of seven (7) years unless law or regulation requires an additional archival period. At any
time, you have the right to remove yourself from our databases by contacting us in writing.

How can you find out about the information contained in our records?

You have the right to know what kind of information the Company retains about you in our files and records, to have
reasonable access to it and to receive a copy. Write to us at the address below if you have questions about information
you would care to receive. Provide your complete name, address and policy number or policy type for which you
applied.

Within thirty (30) business days of receipt of your request, you will be informed in writing of the nature and substance of
locatable and retrievable recorded personal information about you contained in our files. You may review this
information in person or receive a copy at a reasonable fee. We will also identify any person or organization to which
the information was disclosed within the past two (2) year period. In addition, you will be provided the name and
address of any consumer reporting agency that prepared a report about you so that you can contact them to request a
copy.

Following the review of your personal information contained in our file, you may write to us if you believe that any
information should be corrected, amended or deleted. Include a narrative, summarizing what you think is incorrect and
why. Your request will be considered and within thirty (30) business days, the files will either be corrected or you will be
provided with the reasons in writing explaining why the file was not changed. If we do not make the changes, you will
have the right to insert in our file a concise statement containing what you believe to be the correct, relevant, or fair
information and explaining why you believe the information in your file is improper. We will notify persons or
organizations designated by you to whom we have previously disclosed the information of the change or your
statement. Subsequent disclosures to any other persons or organizations will include a copy of your statement.

How do we protect the confidentiality of information about you?

 First Chicago Insurance Company maintains appropriate security standards and procedures to prevent unauthorized
access to your information in whatever medium it is stored. We limit employee access to personally identifiable
information to those with a business reason for acquiring such information. First Chicago also believes in educating our
employees so that they will understand the importance of confidentiality of personal information, and in taking
appropriate measures to enforce employee privacy responsibilities.

How can you opt out of disclosures of your nonpublic personal financial information to non-affiliated third
parties?

If you prefer that we not disclose nonpublic personal financial information about you to nonaffiliated third parties, you
may opt out of those disclosures, that is, you may direct us not to make those disclosures (other than disclosures
permitted by law). If you wish to opt-out of disclosures to nonaffiliated third parties, you may call us toll-free at (888)
262-8864.

First Chicago Insurance Company

6640 S. Cicero Avenue Bedford
Park, IL 60638
(888) 262-8864 or (708) 552-4400 www.firstchicagoinsurance.com

FCMSMP09010116 Page 2 of 2
FIRST CHICAGO INSURANCE COMPANY
(Receipt)
INSUREONLINE.COM Receipt #: 1
6640 S CICERO AVE Receipt Time And Date: 11/01/2020 04:20 PM
BEDFORD PARK, IL, 60623 Producer/CSR: INSUREONLINE.COM - BECERRA O
(708) 730-6000

JEFFERY L SEAT FIRST CHICAGO INSURANCE

COMPANY
802 N JEFFERSON ST 6640 S. CICERO
SPRINGFIELD, MO, 65802 BEDFORD PARK, IL, 60638
(417) 522-9128 708-552-4400

Payment Amount Due To Company - Total: $97.00

Date / Time Payment Type Transaction CSR Amount

Type

11/01/2020 04:20 Other Payment INSUREONLINE.COM - 97.00

BECERRA O

Payment Amount Due To Company - Total: $97.00

Date / Time Payment Type Transaction Type CSR Amount

11/01/2020 04:20 Other Payment INSUREONLINE.COM - BECERRA O 97.00

Agency Fees - Total: $0.00

 Date / Time Payment Type Transaction Type CSR Amount

Insurance Company: FIRST CHICAGO INSURANCE COMPANY Policy #: MOV 619219-00

Phone #: 708-552-4400 Effective Date: 11/01/2020
Expiration Date: 05/01/2021

Insured Signature: _______________________________________________________ Date: _______________

Agents Signature: INSUREONLINE.COM - BECERRA O Date: _______________

Policy Holder: Producer:

JEFFERY L SEAT INSUREONLINE.COM
802 N JEFFERSON ST 6640 S CICERO AVE
SPRINGFIELD, MO 65802 BEDFORD PARK, IL 60623
(708) 730-6000
11/01/2020

Dear Jeffery L Seat,

First Chicago Insurance Company and Insureonline.com - Becerra O would like to take this opportunity to thank you for
your business. Choosing an Insurance Company is an important decision. We know you will be pleased with your decision
to purchase a policy from a Producer and Company that value you as a customer, and are dedicated to keeping you as a
customer for years to come.

Enclosed with this letter you will find the following important documents:

1. Your insurance identification card, to be carried in your vehicle at all times.

2. Your policy declarations page for your records.
3. Your Missouri Personal Auto Policy.
Below you will see a schedule of the payments for the policy term.
Conditional Payment Schedule*

June 01, 2020 $62.80

July 01, 2020 $62.80
August 01, 2020 $62.80
September 01, 2020 $62.80
October 01, 2020 $62.80
Installment Fee Included per payment $12.00

Thank you for your Business!!!

Sincerely,

First Chicago Insurance Company and Insureonline.com - Becerra O

* The Conditional Payment Schedule shown has been printed for your convenience to prepare you for upcoming payment
amounts and due dates. However, this schedule assumes that all payments have been made on time and no changes
have been made to the policy. Any late payments and/or endorsements to the policy may affect your payment due date, as
well as the amount due. Therefore, it is extremely important that you pay your premiums according to the billing invoice
statements mailed to your address, which will always supersede the Conditional Payment Schedule.