X CALIFORNIA SPECIAL

CALIFORNIA RSVP
CALIFORNIA DELUXE
Infinity Insurance Company POLICY NUMBER: 104601191219001
P.O. Box 830189 AUTO APPLICATION VERSION: 8.10 11/24/2014
Birmingham, AL 35283-0189 / 1-800-782-1020
APPLICANT INFORMATION PRODUCER INFORMATION
Name: Linda White Producer Code: 10460-511830
Address: 4230 HIGHWAY 108 Name: INSURANCE ZEBRA, INC
City/State/Zip: RIVERBANK, CA 95367 Address: 301 Chicon St Ste A
Home Phone: 209-312-8036 Work Phone: City/State/Zip: AUSTIN TX 78702
SSN: Phone: 888-255-4364 Fax: 512-910-8558

Garage Information
X Same as Mailing Address
Garaging Address: 4230 HIGHWAY 108
City/State/Zip: RIVERBANK CA 95367

GENERAL INFORMATION
TERM PROGRAM TYPE EFFECTIVE DATE EFFECTIVE TIME EXPIRATION DATE EXPIRATION TIME

12 MONTHS Special 06/02/2015 12:01:00 AM 06/02/2016 12:01:00 AM

DRIVER(S) AND/OR RESIDENT(S) OF HOUSEHOLD INFORMATION

All persons age 15 and older, LICENSED OR NOT, who reside with the applicant, and any other drivers of the vehicle(s) on this application.
DRV DRIVER/RESIDENT RELATION TO DATE OF GENDER MARITAL LIVES WITH SR22 REQUIRED SR22 CASE NO
NO APPLICANT BIRTH STATUS APPLICANT

1 Linda White Self 12/15/1962 F Married Yes No

2 Steven White Spouse 05/11/1959 M Married Yes

DRIVER(S) AND/OR RESIDENT(S) OF HOUSEHOLD INFORMATION (continued)

DRV DRIVER/RESIDENT DRIVER'S LICENSE DATE LICENSED CURRENT VALID PRIOR STATE DRV. POINTS
NO NUMBER LICENSE LIC. NUM.

1 Linda White A9949347 01/02/1979 CA N/A 0

2 Steven White 06/02/1975 CA N/A 0

ACCIDENT INFORMATION
A chargeable accident is one where a person is 51% or more responsible and results in bodily injury or death or for an accident that resulted only in damage to property exceeding a
threshold of $1,000.00 for occurrences on or after 12/11/11 or $750.00 for occurrences prior to 12/11/11.
DRV DATE OF DESCRIPTION OF ACCIDENT STATE OR IS ACCIDENT TYPE OF ACCIDENT DOES TOTAL AMOUNT
NO ACCIDENT JURISDICTION WHERE CHARGEABLE OF DAMAGE EXCEED
ACCIDENT OCCURED THRESHOLD AMOUNT

Yes No BI Death PD Only Yes No

VIOLATION INFORMATION
All convicted violations and license suspensions or revocations for the past 60 months must be shown.
DRV VIOLATION CONVICTED DESCRIPTION OF VIOLATION DMV VIOLATION STATE OR COUNTRY OF
NO DATE CODE NUMBER VIOLATION OCCURRENCE

Yes No

VEHICLE INFORMATION
Losses are adjusted based on ACV not to exceed current market Value.

VEH YEAR MAKE MODEL DESCRIPTION VEHICLE IDENTIFICATION NUMBER (VIN)

*1 1999 GMC YUKON YUKON SLE/SLT/DENALI 4DR 4X4 1GKEK13R8XJ757186

* Indicates VIN is incorrect and cannot be reported to the state of California.

VEHICLE INFORMATION (continued)

VEH VEHICLE USE VEH USE POINTS ANNUAL MILEAGE CURRENT VALUE

1 Personal 9000-9999 29919

LIENHOLDER / LESSOR INFORMATION

VEH INTEREST NAME ADDRESS PHONE NUMBER ACCOUNT NUMBER

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CUSTOM & SPECIAL ADD-ON EQUIPMENT - refer to manual for rules and procedures
VEH VALUE OF EACH*** DATE OF PURCHASE DESCRIPTION OF EACH ITEM WHERE PURCHASED

***MAXIMUM TOTAL VALUE OF EQUIPMENT IS $9,999 NEW (STEREO VALUE ON ANY VEHICLE CANNOT EXCEED $1,000).

PREMIUM DISCOUNTS/SURCHARGES INFORMATION

APPLIED TO: DISCOUNT/SURCHARGE DESCRIPTIONS

POLICY
VEHICLE 1
DRIVER 1 Good_drv2-D /

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 SPECIAL PROGRAM
104601191219001 Linda White

POLICY COVERAGE INFORMATION

COVERAGE LIMITS

BODILY INJURY $15,000 each person / $30,000 each accident

PROPERTY DAMAGE $5,000 each accident
UNINSURED MOTORIST - BI NOT TAKEN
UNINSURED MOTORIST - PD NOT TAKEN
MEDICAL PAYMENTS NOT TAKEN
ROADSIDE ASSISTANCE NOT TAKEN
ACCIDENTAL DEATH NOT TAKEN

POLICY DEDUCTIBLE INFORMATION

COL COM REN RA TOW SPE

Vehicle 1 N/A N/A N/A N/A N/A N/A

POLICY PREMIUM INFORMATION

BI PD UMBI UMPD MED ACC

Vehicle 1 $140.00 $167.00 - - - -

* If asterisk denoted next to premium above, coverage includes the Lessor Liability Endorsement (03332 N0799) with Lessor BI Limits of 100/300 and PD limit of 50.

POLICY PREMIUM INFORMATION (continued)

COL COM CDW REN RA TOW SPE VEHICLE TOTAL

Vehicle 1 - - - - - - - $307.00

PREMIUM INFORMATION
Total Premium: $307.00 Down Payment: $32.46
CA Fraud Fee Recoup: $1.76 Down Payment Method: Credit Card
SR22 Fee: $0.00 Installment Fee: $10.00
Total Charges: $308.76 Installments: 11
Installment Amount: $35.12

Notes to Infinity

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 CA_ELE_PP_01 INFINITY INSURANCE COMPANIES
ELECTRONIC SIGNATURE DISCLOSURE AND CONSENT

This Electronic Signature Disclosure and Consent addresses the circumstances under which you agree to use
electronic signatures in doing business with Infinity. If you consent, you may use electronic signatures to sign
documents associated with 1) your application or 2) other insurance transactions during the term of your Infinity
policy. Your consent permits us to send you applicable documents electronically in connection with your
application or other transaction. All electronic communications and documents between Infinity and you will be
considered in writing. Your electronic signature is as legally binding as your signature on a paper document.

Please read this notice carefully before giving your consent. Please print or save for your records a copy
of any electronic communication or document, including this Disclosure and Consent Page, that is
important to you. If you have any trouble with printing or downloading, you may request paper copies by
contacting one of our Customer Service Representatives.

Your Right to Withdraw Your Consent. If you consent and change your mind later, you may withdraw your
consent at any time by calling 800-782-1020. If you do not give consent, or withdraw consent before the
transaction process is complete, we cannot accept and process your transaction until we deliver the appropriate
documents to you on paper.

Change of Your Designated E-Mail Address. If you need to update your e-mail address or other contact
information with Infinity, you may do so by updating your preferences online at www.infinityauto.com or by calling
800-782-1020.

How to Receive Paper Copies. You may obtain paper copies at any time by contacting us at 800-782-1020.
There are no fees associated with requesting paper copies.

Computer Software and Hardware Requirements:

You must have the following listed items and features in order to electronically sign and print Infinity documents:
1. Be able to view the electronic communications and documents on your monitor, which can be done with a
Compatible Internet Browser.
2. Have access to an Internet service account.
3. Use Adobe Acrobat Reader. You will have the option to download your documents in an Adobe Acrobat
PDF file.
4. Be able to receive e-mail. Infinity may require you to validate your e-mail address.
5. Have access to a computer and operating system that can support these functions and software, and that
permits you to either save files on a storage device for later reference or is connected to a printer that will
print out information displayed on your Internet Browser.

If we change the computer software or hardware requirements, we will provide you with advance notice of the
new requirements. If you do not have the required software and/or hardware, or if you do not wish to use
electronic records for any other reason, you can opt for an alternative process by calling 800-782-1020.

Infinity may, in its sole discretion, deliver paper copies of applicable documents if it chooses to do so and
discontinue the provision of electronic documents. Infinity may also require that certain communications from you
be sent to it on paper at a specified address.

X I consent to the use of electronic signatures in connection with my transactions with Infinity,
including delivery of applicable electronic documents. I have been able to read this notice
using my computer and software. I have successfully printed or downloaded a copy of this
notice. I have access to an account with an Internet Service Provider, and I am able to send and
receive e-mail.

I do not consent.

Form Number 00000ESD01

Document Integrity Verified Adobe Document Cloud Transaction Number: XZ5UXKJ73XT554P

 Special Program
3700 Colonnade Parkway, Suite 600
Birmingham, AL 35243
6/2/2015 Infinity Insurance Company

CA_POL_PP_01
APPLICANT ACKNOWLEDGMENT OF POLICY RATING FEATURES

By California Regulation 2632.5 (Rating Factors) all policies must be rated using 3 mandatory factors. The first is your driving record
which we obtain a copy of your motor vehicle record from the state's DMV. The second is your annual mileage driven and the third is
your years of driving experience.
For the second and third mandatory rating factors, we used the information you declared on your application and it is shown below.
Please verify the information below and inform your Agent /Broker if any of this information is incorrect.
The coverage and terms of the policy options available to me have been fully explained and I have made my selection for this policy
and coverages based on that information.

X Rated on a Garaging Address of:

4230 HIGHWAY 108 RIVERBANK CA 95367

X Rated on Drivers Experience of: Continuous Months Licensed

Linda White 437
Steven White 480

X Rated on a Mileage Range of:

GMC YUKON 9000-9999

OTHER COVERAGES THAT ARE AVAILABLE TO YOU:

ROADSIDE ASSISTANCE - When your vehicle is disabled, for a small charge this coverage will provide fuel delivery, flat tire
assistance, lockout service, jump start or towing. Just sign the road service invoice and drive away with no out of pocket expenses.
Selected X Not Selected

RSVP DIRECT REPAIR- When you purchased your RSVP Coverage, you agreed that if you use one of the body shops in our network,
then we will pay 100% of the fair and reasonable charges, less the deductible. When your vehicle is repaired at a body shop in our
network, we will guarantee the repairs for as long as you own the vehicle. If you use a body shop that is not in our network, then we will
pay 80% of the fair and reasonable charges, less the deductible. If you use a body shop that is not in our network, we may require an
inspection of the repairs prior to making any payment.

Selected X Not Selected

Jun 2, 2015 1050am

AM PM
Linda White (Jun 2, APPLICANT'S
2015) SIGNATURE DATE TIME

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 SPECIAL PROGRAM
104601191219001 Linda White

REVIEW OF UNINSURED MOTORISTS COVERAGE

1. Uninsured Motorist Bodily Injury coverage provides that if you suffer bodily injury or sickness, including death, resulting from an accident with a
hit and run driver or a person who does not carry liability insurance, and if he or she is at fault, you may make claim against your own insurance
company for general damages and special damages rather than against the uninsured motorist.

2. Uninsured Motorists Property Damage coverage provides that if your insured car is damaged from a collision with an identified uninsured motor
vehicle, then you may make claim directly against your own insurance company for the property damage to your insured car as long as you are
legally entitled to collect from the owner or operator of the uninsured vehicle. The limit of liability is $3,500 for one automobile damaged in one
accident. Subject to the maximum limit of liability, your insurance company will pay you the actual cash value of your insured car or the amount
necessary to repair or replace it, whichever is less. This coverage is available only if you are covered for Uninsured Motorist Bodily Injury
coverage and your insured car is not covered for collision coverage. A $100 deductible applies.

3. Uninsured Motorists Collision Deductible Waiver coverage provides that if your insured car is damaged as the result of direct physical contact
with an identified uninsured motor vehicle then your deductible under collision coverage will be waived. This coverage is available only if you
are covered for Uninsured Motorists Bodily Injury coverage and your insured car is covered for collision coverage.

AGREEMENT TO COMPLETELY DELETE UNINSURED MOTORISTS COVERAGE FROM THIS POLICY

FORM #01213 R1004
Section 11580.2(2) of the California Insurance Code reads: "The California Insurance Code requires an insurer to provide uninsured motorists
coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor
vehicle. Those provisions also permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a motor
vehicle is operated by a natural person or persons designated by name. Uninsured motorists coverage insures the insured, his or her heirs, or legal
representatives for all sums within the limits established by law, which the person or persons are legally entitled to recover as damages for bodily
injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an uninsured motor vehicle not owned or
operated by the insured or a resident of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in
subdivision(p) of Section 11580.2 of the Insurance Code."
I have read and understand the above and in accordance with the provisions of Sections 11580.2 and 11580.26 of the California Insurance Code
which permit me and the Company to delete uninsured motorists coverage (reviewed above) completely from the policy, I hereby agree with the
Company that the provision in the policy covering bodily injury and property damage caused by an uninsured motor vehicle is deleted completely
from the policy and that the policy does not and will not afford any coverage for bodily injury or property damage caused by an uninsured motor
vehicle.
I also fully understand and agree with the Company that since I have elected not to accept Uninsured Motorists coverage, the Uninsured Motorists
Property Damage coverage (reviewed above) or the Uninsured Motorist Collision Deductible Waiver coverage (reviewed above) is not available to
me. CAUTION: DO NOT SIGN THIS AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND IT. BY SIGNING HERE I ELECT NOT TO
ACCEPT UNINSURED MOTORISTS COVERAGE.

Jun 2, 2015 1050 am AM PM

Linda White (Jun 2, 2015)
APPLICANT'S SIGNATURE DATE TIME

Form Number 02300 R0711 Page 6

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 SPECIAL PROGRAM
104601191219001 Linda White

AGREEMENT VOIDING AUTOMOBILE INSURANCE WHILE A CERTAIN PERSON IS OPERATING YOUR INSURED CAR
FORM # 00540 R1004 CA_DE_PP_01
In consideration of your premium payment, it is agreed that, with respect to the insurance afforded under this policy, or any continuation, renewal or replacement of the
policy by YOU, or the reinstatement of this policy within 30 days of any lapse thereof, we shall not be liable for loss, damage, and/or liability caused while YOUR
INSURED CAR is being driven or operated by the following named person.
CAUTION: DO NOT SIGN THIS AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND IT.

NAME OF PERSON BEING EXCLUDED: Steven White

Jun 2, 2015 1050am AM PM

Linda White (Jun 2, 2015)APPLICANT'S SIGNATURE DATE TIME

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MILEAGE INFORMATION

1. If your vehicle is used for commute purposes, please list the address of the workplace, school, or other destination where the vehicle will be
driven. CA_MLG_PP_01
Vehicle # 1 Street N/A City N/A State N/A Zip N/A

2. List the number of days the vehicle will be used for commuting.

Vehicle # 1 5

3. Estimate the total number of annual miles to be driven in the next 12 months.

Vehicle # 1 9000-9999

4. Please give the reason for any difference between the estimate for the upcoming 12 months and the miles driven for the previous 12 months
if applicable.

Vehicle # 1 N/A

5. List the current odometer reading of the vehicle shown on the policy.

Vehicle # 1 Not Answered

6. Attach the service records that reflect the odometer reading for the most recent 12 month period. (Optional - This information is not required,
but may support a lower premium.)

Vehicle # 1 Not Answered

REMARKS OR OTHER CHANGES:

Vehicle # 1 Not Answered

I hereby certify that I have read all the questions on this questionnaire and have disclosed the requested information. I also certify that all
information contained in this questionnaire is accurate and complete. I understand these changes and information included in this questionnaire
may be endorsed and made part of my policy.

Jun 2, 2015 1050am

AM PM
Linda White (Jun 2, 2015) APPLICANT'S SIGNATURE DATE TIME

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Acknowledgement That INFINITY Offers Multiple Programs CA_ACK_PP_01

My broker-agent has explained to me that Infinity offers multiple programs. The three programs, Special, RSVP and Deluxe, have
price and coverage differences designed to meet individual needs. I understand that Infinity's explanation below represents only some
of the differences in these programs' coverages and conditions. I understand I may ask my broker to explain any other coverage
distinctions not appearing below that might apply to my situation.

Liability Coverage
Bodily Injury Limits -- Special and Deluxe offers Bodily Injury limits up to $100,000 per person/$300,000 accident, while RSVP's
maximum limits are $25,000 per person/$50,000 accident. In the Special and RSVP Programs, the Bodily Injury and Property
Damage limits will be reduce to the state statutory limits of Bodily Injury $15,000 per person/$30,000 per accident and Property
Damage $5,000 per accident in the event a permissive user is driving the vehicle. The Deluxe Program does not have this limitation.

Replacement Autos -- The Special and Deluxe policies provide uninterrupted coverage for a replacement auto as long as Infinity is
notified within 30 days after the acquisition of a replacement. The RSVP policy provides no liability coverage on a replacement auto
until the time Infinity is asked to add the coverage you want.

Newly Acquired Autos -- Receive 30 days automatic coverage in the Deluxe Policy while the Special allows 14 days automatic
coverage. The RSVP Policy does not allow any automatic coverage. New Auto Replacement cost is provided only in the Deluxe
Program.

Coverage For Damage To The Insured Auto (Collision, Other Than Collision)
RSVP has a provision for choosing repair shops that Infinity recommends. This is important in two respects:

(1) RSVP provides for two levels of repair cost coverage. If a policyholder chooses a repair shop that is not in Infinity's
network, Infinity will cover 80% of the fair and reasonable charges, less the deductible. If a policyholder chooses a repair
shop that is in Infinity's network, Infinity will cover 100% of the fair and reasonable charges, less the deductible. If a
policyholder chooses a repair shop that is not in Infinity's network, Infinity may require an inspection of the repairs prior to
making any payment.

(2) Infinity guarantees repairs performed by recommended repair shops as long as the policyholder owns the auto. Infinity
does not guarantee repairs by repair shops they do not recommend, although such shops may offer guarantees of their
own.

Special and Deluxe provide for payment of 100% of the fair and reasonable repair charges less the deductible, regardless of whether
a policyholder chooses a recommended repair shop. However, by endorsement, Special and Deluxe may be changed to provide the
same two levels of repair cost coverage as RSVP at a reduced premium.

Uninsured Motorists, Collision, Other Than Collision Coverages

RSVP contains a Mandatory Binding Arbitration clause. This means that in the event of a dispute between the policy holder and
Infinity, the two parties will not sue each other, but will settle their disputes through arbitration. Special and Deluxe do not contain this
requirement.

By signing below I acknowledge that the differences in Special, RSVP and Deluxe coverages and costs that are important to
me have been fully explained by my broker-agent. I have been provided with premium quotes for the Special, RSVP and
Deluxe programs and the program I have chosen is selected below. I understand that if I want other price quotes I may make
such requests to my broker-agent or to Infinity (toll free 1-800-782-1020).

RSVP X Special Deluxe

Jun 2, 2015 1050am AM PM

Linda White (Jun 2, 2015)
APPLICANT'S SIGNATURE DATE TIME

Steven Cummings 06/02/2015 12:01:00 CST X AM PM

BROKER-AGENT'S SIGNATURE DATE TIME

*By entering Broker-Agent name electronically, The Broker-Agent certifies that this constitutes his/her electronic Signature.
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 SPECIAL PROGRAM
104601191219001 Linda White

THIS APPLICATION BECOMES PART OF YOUR INSURANCE POLICY CA_APP_PP_01

PRIVACY DISCLOSURE: In connection with your application for an automobile insurance policy, we may obtain consumer reports, Motor Vehicle Reports,
Comprehensive Loss Underwriting Evaluations or other personal or privileged information about you and all other residents listed on this application from third parties. It
is not our policy to disclose this information to third parties without your authorization, but in certain circumstances we may do so. You have the right to access and
correct all personal information collected. At your request, we will provide the name and address of the consumer reporting agency that furnished any of this information.
At your request, we will provide you with more detailed information regarding our collection, use, and disclosure of personal information and your rights to access and
correct such information. For more information, call Customer Service at 1-800-782-1020.

APPLICANT'S STATEMENT - READ BEFORE SIGNING

WARNING

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE OR SHE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS COMMITTING INSURANCE
FRAUD AND WILL BE PROSECUTED TO THE FULLEST EXTENT OF THE LAW.
I hereby apply to the Company for a policy of insurance as set forth in this application on the basis of my statements contained herein. By signing
below I understand that this application becomes a part of my policy and is a legal document and I certify that:

1. I have listed all operators of the vehicles listed on this application and all information about these persons is correct. This includes anyone that
may operate my vehicle(s) on a regular or frequent basis, children away from home or away at school, and all persons age 15 or older who
live with me. I agree to notify the Company of any changes in operators or licensing of household residents. I acknowledge that failure to
notify Infinity of i. any member of my household age 15 and older, licensed or not, and ii. any change in driving status for any
person currently listed or added on my policy in the future, pursuant to my obligation to keep Infinity informed, is a
misrepresentation that may materially affect the risk accepted by the Company and may render my policy null and void.
2. I have reported any business or commercial use of my vehicle to the Company. I understand that acceptable business use is not covered
unless I have disclosed the specific use on this application and paid a premium for the Business Use Endorsement.
3. My principal residence address and place of vehicle(s) garaging is (are) the address(es) shown in this application for ten (10) or more months
each year.
4. Any custom and special add-on equipment that I want covered has been declared on this application and A PREMIUM PAID FOR
THIS ADDITIONAL COVERAGE.
I understand that:
5. The policy I am purchasing may contain unique exclusions, conditions and restrictions I should read.
6. Coverage will not be afforded and may render my policy null and void if a regular operator is not listed on the declarations page and
a premium paid.
7. No coverage of any kind shall be provided:
a. If an operator that is specifically excluded by endorsement uses my vehicle.
b. If I allow an unlicensed person to operate my vehicle.
8. By purchasing this policy it is my obligation to give the Company prior notification of any changes in the statements and information contained
in this application. Failure to notify the Company of such changes is a misrepresentation that may materially affect the risk accepted by the
Company and may render my policy null and void.
9. The quote I have received has been developed using this application. The Company may verify certain information, and, if necessary correct
the premium in accordance with its rate filings. If I do not want to continue coverage, I understand that cancellation will be calculated based
upon the correct premium. The Company will include a cancellation charge of $20 if cancellation is at my request.
10. No coverage is provided and the policy shall be null and void from inception:
a. If any information in this application is false, misleading, or would materially affect acceptance of the risk by the Company, or
b. If my down payment, partial or full, is not honored by my bank. This applies whether my payment is by check, credit card, or by electronic
funds transfer.
11. The following payment rules apply to this policy:
a. If the Company receives my payment after the due date, I will owe a late charge.
b. If my policy is rewritten with a lapse in coverage due to late payment, I will owe a Rewrite charge, and the rates in effect at that time shall
apply.
c. If my Renewal payment is received after policy expiration, my policy will be renewed with a lapse in coverage, using rates in effect at that
time
d. The company will apply any payment I make first to any installment fee or other non premium charges that are due and then will apply the
balance of my payment to any premium due. If the balance of the payment is less than the premium due, the policy may be canceled.
e. Any outstanding balance from the previous policy term will be satisfied first from any Rewrite or Renewal payment amount.
12. If I choose to receive the RSVP Direct Repair Discount, I understand: THAT MY POLICY BENEFITS WILL BE SUBSTANTIALLY LOWER IF I
CHOOSE TO INCUR REPAIR CHARGES BY A VENDOR WHICH IS NOT A DESIGNATED RSVP PROVIDER. THE COMPANY HAS A
RIGHT TO INSPECT ALL REPAIRS PRIOR TO MAKING A PAYMENT.
13. The producer named in this application is acting as my broker if so indicated in the Producer Statement.
14. Any broker fee is determined, collected, and retained solely by the Broker named on this application.
15. California Insurance Regulations require that brokers present applicants with a written fee disclosure.
16. Agents and brokers receive commission and may receive other consideration from the Company.

The coverage I am applying for has been fully explained to me. I certify that the statements and information in this application are true
and accurate. By signing below, I acknowledge that I have read the warnings and statements listed on this application.

Jun 2, 2015 1050am

Linda White (Jun 2, 2015)
AM PM
APPLICANT'S SIGNATURE - MUST BE SIGNED DATE TIME

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 SPECIAL PROGRAM
104601191219001 Linda White

PRODUCER'S STATEMENT
To the best of my knowledge, all information contained herein is correct, the statements herein are those of the applicant. The applicant
and I are retaining a duplicate signed copy hereof.
I am acting as the applicant's broker in this transaction, and I am legally qualified to submit this application on behalf of the
applicant.
X I am acting as Infinity's appointed agent.

Producer: Steven Cummings Date 6/2/2015 Time 12:44 CST X AM PM

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 SPECIAL PROGRAM
104601191219001 Linda White

CREDIT CARD PAYMENT AUTHORIZATION - If the insured wants to charge the premium to a credit card, the following must be completed:
CHECK ONE: VISA AMERICAN EXPRESS AMOUNT CHARGED Full Premium $________________
X MASTERCARD X Down Payment $________________
$32.46
Credit Card Number _____________________________
XXXXXXXXXXXX7977 Expiration Date ________
05/2016 (Mo/Yr)
Authorization Number ____________________________ (Company Use)
I understand that if this credit card transaction is denied for any reason, no coverage will be bound or in force.
CARDHOLDER'S SIGNATURE______________________________________
Linda White
RECURRING CREDIT CARD AUTHORIZATION - If the insured wants to charge the installments to a credit card, the following must be
completed:
CHECK ONE: VISA X MASTERCARD AMERICAN EXPRESS

Credit Card Number _____________________________

XXXXXXXXXXXX7977 Expiration Date ___________
05/2016 (Mo/Yr)

Authorization Number ____________________________ (Company Use)

All installemnts on the policy will be charged to the credit card. I understand that if this credit card transaction is denied for any reason, no coverage
will be bound or in force.

CARDHOLDER'S SIGNATURE______________________________________
Linda White

Document Integrity Verified Adobe Document Cloud Transaction Number: XZ5UXKJ73XT554P

 www.infinityauto.com
Customer Service Phone: (800)782-1020
Customer Service Fax: (800)782-2218

To: Infinity Special Agency: INSURANCE ZEBRA, INC

Fax: (800)782-2218 Phone: 888-255-4364
Sender: RE: New Policy Fax

Policy Number: 104-60119-1219-001 Date: Uploaded on 6/2/201512:44:57 PM CDT

Named Insured: White, Linda Pages:

These documents should be faxed along with this cover sheet within 72 hours of the policy upload:

no suspense

Comments:

Form: CMNFAX01

Do Not Write Below This Line

If fax not available, mail to:

Infinity Insurance Companies
P.O. Box 830807
Birmingham, AL 35283-0807

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 Special Program
PO Box 830189
Birmingham, AL 35283-0189
Underwritten by: Infinity Insurance Company

Insured Receipt

Policy Number: 104-60119-1219-001 Agency: INSURANCE ZEBRA, INC

Named Insured: Linda White Address: 301 Chicon St Ste A

Address: 4230 HIGHWAY 108 AUSTIN TX 78702

RIVERBANK, CA 95367

This acknowledges receipt of $32.46 to Infinity by direct payment of cash, check, money order or credit card to the
agency. The payment is made as a down payment on the policy number noted above.

Our acceptance of your payment does not guarantee coverage. If you have paid your down payment or installment by
check and your bank returns the check unpaid, the down payment or installment will be considered never paid to the
insurance company. On a new policy, this means that your insurance never went into force and that you are not
covered. If you are making a payment on a current policy, any outstanding cancellation will take effect and/or any new
payments due will be considered unpaid. Payment of all amounts due is necessary to be considered for reinstatement
on current policies which are in the process of being cancelled. Our acceptance of your check in no way promises
continuation of coverage.

Date: 6/2/2015 Time: 12:44:57 PM CDT

Agency Receipt

Policy Number: 104-60119-1219-001 Agency: INSURANCE ZEBRA, INC

Named Insured: Linda White Address: 301 Chicon St Ste A

Address: 4230 HIGHWAY 108 AUSTIN TX 78702

RIVERBANK, CA 95367

This acknowledges receipt of $32.46 to Infinity by direct payment of cash, check, money order or credit card to the
agency. The payment is made as a down payment on the policy number noted above.

Date: 6/2/2015 Time: 12:44:57 PM CDT

Form No. CMNRCT01

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 Special Program
3700 Colonnade Parkway, Suite 600
Birmingham, AL 35243
Infinity Insurance Company

INVOICE

Important: Give this bill to the Applicant -- Do not submit with application.

Policy Number: 104-60119-1219-001 Agency: INSURANCE ZEBRA, INC

Named Insured: Linda White Address: 301 Chicon St Ste A

Address: 4230 HIGHWAY 108 AUSTIN TX 78702

RIVERBANK, CA 95367

This is your First Bill (Installment)

You may not receive another Bill (unless your Premium changes)

Infinity must receive $35.12

To: Infinity Insurance Companies

P.O. Box 830189
Birmingham, AL 35283-0189

By 07/02/2015 to avoid Cancellation or Late Fees.

Do Not Ignore This Statement

Return The Top Portion with Your Payment

Your remaining installments:

Due Date Installment Amount Fee Amount Total Payment Due

07/02/2015 $25.12 $10.00 $35.12
08/02/2015 $25.12 $10.00 $35.12
09/02/2015 $25.12 $10.00 $35.12
10/02/2015 $25.12 $10.00 $35.12
11/02/2015 $25.12 $10.00 $35.12
12/02/2015 $25.12 $10.00 $35.12
01/02/2016 $25.12 $10.00 $35.12
02/02/2016 $25.12 $10.00 $35.12
03/02/2016 $25.12 $10.00 $35.12
04/02/2016 $25.12 $10.00 $35.12
05/02/2016 $25.12 $10.00 $35.12

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 Special Program
3700 Colonnade Parkway, Suite 600
Birmingham, AL 35243
Infinity Insurance Company

Due Date Installment Amount Fee Amount Total Payment Due

You will receive bills for these amounts and due dates, but your receipt or non-receipt of this bill will not prevent
your policy from cancelling if Infinity does not receive your payment by the due date indicated. You may be
charged a late fee for payments not received by the due date.

When your application is submitted, your first bill and the above installments may change. Watch your mail for such
changes.

For your convenience, credit card and check payments can also be made at InfinityAuto.com or by calling
Customer Service at (800)782-1020.

Form: CMNINV01

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 Temporary Insurance Card
Company: Infinity Insurance Company
PO Box 830807 Birmingham, AL 35283-0807
Policy No: 104601191219001 Effective Date: 06/02/2015
Vehicle(s) VIN
1999 GMC YUKON 1GKEK13R8XJ757186

Insured(s) Producer
Linda White INSURANCE ZEBRA, INC
301 Chicon St Ste A
AUSTIN TX 78702
8882554364

Insurance Identification Card Issued Pursuant to California Law. NAIC # 22268

This card expires 30 days after effective date shown. Any alteration will void this card!

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 301 Chicon St, Suite A - Austin, TX 78702


CaliforniaBrokerFeeAgreement

Linda White
1.Thepartiestothisagreementare__________________________________________(Client)AND
INSURANCEZEBRAINC.CaliforniaDepartmentofInsuranceLicenseNumber:0143637(Broker).

2.CLIENTappointstheBROKERasCLIENTSinsurancebrokerofrecord.

Jun 2, 2015
3.Thisagreementshallbecomeoperativeon__________________(date)andshallcontinueinfullforce
untilterminatedbyeitherparty.

4.BROKERagreestorepresentCLIENThonestlyandcompetently.

5.CLIENTagreestopayBROKERabrokerfeeforBROKERSservices.Thebrokerfeeis$50.00.The
brokerfeeISNOTrefundable.

6.BROKERmaynoworinthefuturechargeCLIENT,andCLIENTagreestopay,additionalfee(s)forthe
serviceslistedbelow.Theadditionalfeesandservicesare:



Services Amount
SR22 $20.00



7.FollowingarethenatureandamountofallfeesknowtoBROKERthatwillbechargedbythepersons
otherthanBROKERortheinsurancecompanyinconnectionwithcurrentplacementofCLIENTS
insurance.ThesefeesarenotretainedbyBROKER.






Linda White (Jun 2, 2015)
_________________________________________ Jun 2, 2015
________________
ClientSignature Date

Steven Cummings (Jun 2, 2015)
_________________________________________ Jun 2, 2015
________________
BrokerSignature Date

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 301 Chicon St, Suite A - Austin, TX 78702

CaliforniaStandardBrokerDisclosure

I Donotsignanybrokerfeeagreementunlessallofitsblanklinesandspacedhavebeenfilledin
andyouhavereadtheagreementcarefully.

II Yourinsurancebrokerrepresentsyou,theconsumer,andisentitledtochargeabrokerfeeifhe/she
chooses.Thisfeeisnotsetbylaw,andmaybenegotiablebetweenyouandthebroker.

III Itisillegalorimproperforaninsurancebrokertochargeyouafeeforplacingcoveragesolelywith
theCaliforniaAutomobileAssignedRiskPlanortheCaliforniaFAIRPlan.Feesmaybechargedfor
placementofothercoverages

IV Brokerfeesareoftennonrefundableevenifyoucancelyourcoverage.Refertoyourbrokerfee
agreementtoseeifyourbrokerfeeisnonrefundable.However,youmaybeentitledtoafullrefundofa
brokerfeeifyourbrokeractedincompetentlyordishonestly.Unresolveddisputesovernonrefundedbroker
feescanbeforwardedtotheDepartmentofInsuranceforreview.

V Youareentitledtoobtainandkeepacompletedcopyofthisdisclosureandanybrokerfee
agreementyousign.

VI Yourbrokermayreceivecommissionfrominsurancecompany(ies)forplacingyourinsurance.This
commissionmaybepaidtoyourbrokerbytheinsurancecompany(ies)inadditiontoanybrokerfeeyou
pay.

VII Ifyouwillbepayingyourpremiumininstallmentstoafinancecompany,bylawyoumustreceivea
copyofapremiumfinancedisclosureandagreement.Besuretoobtainandreadthosedocumentsbefore
signingapremiumfinanceagreement.Also,askthebrokeriftheinsureroffersitsowninstallmentpayment
plan.Insurerinstallmentplansareoftencheaperthanpremiumfinancingthroughaseparatepremium
financecompany.

VIII Ifyourbrokerisplacingautomobilecoverage,yourbrokermustprovideyouwithacopyofthe
currentDepartmentofInsurancepamphletAutomobileInsurance.Ifyourbrokerisplacingresidential
coverage,yourbrokermustprovideyouwithacopyofthecurrentDepartmentofInsurancepamphlet
ResidentialInsurance.Bysigningthisdisclosureyouacknowledgereceiptoftheappropriatepamphlet(s).


Clientinitials:______
LW

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 Consumer Guide to AUTOMOBILE INSURANCE
FIVE TIPS TO HELP YOU BUY AUTO INSURANCE
Tip 1: Obtain the brokers
business card.
If you are reading this pamphlet, it was
probably given to you by an insurance
broker or solicitor. (A solicitor is a
person who works for a broker. In the
rest of this pamphlet we will use the
term broker to include both solicitors
and brokers.) All brokers must be
licensed by the State of California
Department of Insurance. To obtain a
license, a broker must take a class on
insurance, pass an exam, and meet other
requirements. However, a few people
try to sell insurance without a license.
Make sure your broker is currently
licensed in California.
By law, a broker must include his or her
license number on his or her business
card, and on any written price quote
given to you. Obtain the business card
Prepared for consumers by the California Department of Insurance. A broker must give this pamphlet to its insured whenever the broker charges a broker fee and sells an auto
policy, pursuant to Title 10 of the California Code of Regulations Chapter 5, Subchapter 1, Article 6.8, Appendix A.
Document Integrity Verified
of each broker who talks to you about insurance company and an
insurance! If the broker says he or she
insurance broker.
does not have a business card, ask him
or her to write down his or her first,
Brokers are not insurance companies;
middle and last name, along with his or
they are independent insurance
her license number. Keep the business
salespersons. The broker represents
card or piece of paper along with your
you, the client. In order to find
other insurance papers.
insurance for you, a broker will usually
review the premium rates and coverages
The California Department of Insurance
of several insurance companies.
website (www.insurance.ca.gov) lists all
licensed brokers. You can find out
A broker will usually have the words
whether the person who helped you buy
insurance agency, insurance
insurance is licensed by checking this
brokers, insurance brokerage, or
website, or by calling the Department of
insurance services in its business
Insurance at (800) 927-HELP or (213)
name. An insurance company is
897-8921. If you buy insurance from a
responsible for paying any claims you
person who does not have a license, you
have; a broker is not. An insurance
are legally entitled to have any broker
company will usually have the word
fee you paid refunded.
insurance company, casualty
company, indemnity company,
Tip 2: Understand the insurance underwriters or assurance
difference between an company in its name.
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Page 2
Some insurance companies will use the
services of another business, called a
managing general agent or general
agent. These businesses may perform
underwriting, claims handling and
billing on behalf of the insurance
company issuing the policy.
Remember, when purchasing insurance
through a broker you could be dealing
with several different companies: 1) the
insurance broker; 2) a managing general
agent; 3) the insurance company. In
addition, if you need to borrow money
to help pay your premium, another type
of company, a premium finance
company, may be involved.
Tip 3: Obtain and keep
important insurance papers.
Application
When you apply for insurance, the
broker will probably help you complete
an insurance application form. This
form will be sent to the insurance
company. Read the application
carefully before you sign it. Do not
sign the application if any information
on it is missing or incorrect, even if the
Document Integrity Verified
broker says it is ok to do so, or that the
wrong information will save you
money. An insurance company can a binder if you need coverage quickly.
sometimes deny your claim if you
signed an application with incorrect
information. Obtain and keep a copy of
the application.
Binder
When an insurance company accepts an
application, it typically mails the actual
insurance policy several weeks later. If
you need insurance right away or within
a few weeks, the broker should provide
you with an insurance form called a
binder or certificate of insurance. for a small, extra charge. However, not
These forms provide you with proof that
you have insurance coverage until the
insurance company actually sends you
the policy. A binder or certificate
should show the name of the insurance
company, the date your insurance takes
effect, your name, a description of your
vehicle, the types of coverage you
bought, the liability coverage limit if
you bought liability insurance, and
deductibles if you bought
comprehensive or collision coverage.
Obtain and keep the binder. Dont
accept a brokers word that you are
covered or will be covered as of a
certain, future date; get it in writing.
Every broker should be able to give you
Receipt
You will usually have to pay some or all
of the premium to the broker when you
apply for insurance. Obtain a signed
receipt for your premium payment.
Insurance company payment plans
Many people choose to pay their
insurance premium in installments. For
these people, the insurance company
may offer an installment payment plan
all companies offer such plans.
Premium finance companies
Another option for people who can not,
or prefer not to, pay their insurance
premium all at once, is to obtain a loan
from a premium finance company.
With premium financing, you will pay a
down payment to the broker when you
apply for the insurance. The finance
company will pay the full premium to
the insurance company. After that, you
will reimburse the finance company
over several months. Be aware that
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premium financing typically includes a
non-refundable fee and an interest rate
that is usually much higher than banks
impose on credit cards.
In order to obtain premium financing, a
premium finance application form must
be completed. Do not let a broker sign
this form for you obtain it, take your
time to read it carefully, ask the broker
to explain anything you dont
understand, then sign it if you still want
to have premium financing. The form
will contain very important information
how much you will have to pay, how
often, how much the fees are, what the
interest rate is, and what the total
principal and interest will be. Once you
sign-up for premium financing, it may
be expensive to cancel it.
If a broker suggests using a premium
finance company, be sure to ask the
broker about insurance companies that
offer installment payment plans. Even
Last Revised October 27, 2000. Copyright California Department of Insurance. Permission is granted to any person to reproduce this pamphlet for non-commercial purposes, or to comply
with the California Department of Insurance broker fee regulations (Title 10 of the California Code of Regulations Chapter 5, Subchapter 1, Article 6.8, Appendix A).
LW
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if an insurance company with an
installment plan charges more premium
than an insurance company that does
not have an installment plan, your total
cost of insurance may be less if you
dont have to pay loan fees and interest
to a premium finance company.
Broker fee disclosure and
agreement
To charge a broker fee, a broker must
have you sign a broker fee agreement,
and must give you a special broker fee
disclosure. Obtain copies of both of
these documents.
Tip 4: Take your time and ask
questions.
Read all forms carefully, and take your
time. Dont let anyone try to rush you.
Ask questions a broker should take
the time to explain everything slowly
and with words you understand. If a
broker makes any promise to you, get it
in writing. Never sign any form that
has empty spaces have the broker
draw a line through those spaces before
you sign the form.
Tip 5: Find out more about
insurance.
Insurance is expensive. You can save a
lot of money, possibly hundreds of
dollars each year, year after year, by
learning more about insurance. A good
place to start is at the Department of
Insurance website at
www.insurance.ca.gov, or by getting
brochures from the Department of
Insurance help line, 1-(800) 927-HELP
(4357) or (213) 897-8921. You can
obtain pamphlets about many insurance
topics, such as different types of
insurance, how to file claims, and how
to buy insurance.
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