Policy_Summary

lAPPLICATION NUMBER RIN1717811 AMERICAN BANKERS INSURANCE COMPANY OF FLORIDA 11222 Quail Roost Drive, Miami, FL 33157 -6596 (305) 253-2244 RENTERS INSURANCE APPLICATION Applicant's Name Requested Coverage Effective Date Robel Regassa 2012-07-22 Applicant's Insured Address and Unit/Apartment Number, City, State, ZIP Code 9332 EDMONSTON RD 104, GREENBELT, MD 20770 Mailing Address (if different from insured address), City, State, ZIP Code Applicant's Phone Number (571)314-0227 Construction Type: N/A E-Mail Address robel.regassa@gmail.com Type of Dwelling: Apartment/Condominium Interested Party Name N/A Interested Party Address N/A PERSONAL PROPERTY COVERAGE State: MD $5,000 Personal Property Coverage Replacement Cost Coverage INCLUDED. Sewer or Drain Backup Coverage NOT INCLUDED. Term of Coverage: 1 YEAR. PAYMENT METHOD Credit Card Visa XXXXXXXXXXXX4314 02/2015 Payment Plan Option: 8 1 Initial Payment of $14.56 7 Installment Payments: $14.92 A $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 $4.00 service 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, $500 Medical Payments per Person to Others, $500 Property Dama ge to Others, and a $250 deductible will be applied to Personal Property Coverage under all plans. This policy provides only limited coverage for certain classes of property. By typing my full name below as it appears on my account to be billed, I req uest enrollment in Renters Insurance and authorize the billing of the cost of the insurance to my account to be billed. I agree to the use of electronic enrollment 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 by e-mail at the indicated e-mail address regarding this insurance, including the status of my insurance application. Applicant's Electronic Signature Robel Regassa Agent's Name (if applicable) Agent’s License Number (if applicable) Application Date 07/21/2012 Agent's Number Copyright ©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 the following business day after the Company receives the application and payment; or 2. The requested coverage effective date on the application if that date is later than the dates specified in 1. Additionally, all effective dates are subject to Company moratoriums. A4009-1007 Tracking Code Copyright ©2005 American Bankers Insurance Company of Florida FRAUD NOTICE Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 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 of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company, or other person files an application 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 or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and 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 insurance policy 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 or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact mater ial thereto commits a fraudulent 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 loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Washington, D.C.: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING T HE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF 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 insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Applicant's Electronic Signature Robel Regassa Agent's Name (if applicable) Application Date 07/21/2012 Agent's Number Tracking Code Copyright ©2005 American Bankers Insurance Company of Florida