Acknowledgment of Consent

Drive Safe & SaveTM

Legislation requires your signature to acknowledge and agree you have received and reviewed the terms of consent for Drive Safe &
Save.
The consent contains the requirements for participation in Drive Safe & Save, which empowers drivers to personalize their auto
premium based on how much and sometimes how safely they drive. Ensure you have reviewed the information carefully, as it may
have changed since you last agreed to the requirements.
If you have not done so already, sign, date, and return this form, confirming your consent to enroll in Drive Safe & Save. If we don’t
receive this signed form within 35 days from the date of your Drive Safe & Save enrollment, we will remove the discount back to the
date it was added to your policy, which may result in a balance due.
I acknowledge and agree that I have received and reviewed the terms of consent for Drive Safe & Save.

MICHAEL LIM
Name of Applicant
130 7914-F22-26
Application/policy number
2011 SCION TC - 2D HB GAS
Vehicle

#$S01 #$D01

Signature of applicant Date (MM/DD/YYYY)

1008066 2002 150624 202 09-22-2021