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Filing # 121332494 E-Filed 02/12/2021 03:16:33 PM
IN THE CIRCUIT COURT OF THE 774
JUDICIAL CIRCUIT IN AND FOR FLAGLER
COUNTY, FLORIDA
DIRECT GENERAL INSURANCE COMPANY, Case No.: 2921 CA 000079
Plaintiff,
ANGEL ENRIQUE CRUZ, VICTOR JOSE
PERALTA, and VICTOR JOSE PERALTA as
the Parent, Natural and Legal Guardian of
JONAELL R. TORRES, a minor,
Defendant(s).
PLAINTIFF’S COMBINED FIRST REQUEST FOR ADMISSIONS AND REQUEST FOR
PRODUCTION TO DEFENDANT, ANGEL ENRIQUE CRUZ
COMES NOW, the Plaintiff, DIRECT GENERAL INSURANCE COMPANY, by and through
its undersigned counsel and pursuant to F.R.C.P. 1.370 and 1.350, hereby files this, Plaintiff's
Combined First Request for Admissions and Request for Production to the Defendant, ANGEL
ENRIQUE CRUZ, directing that the Defendant admit or deny the following allegations and
produce all responsive documents, within forty-five (45) days as follows:
REQUEST FOR ADMISSION #1:
1. Admit that ANGEL ENRIQUE CRUZ made a misrepresentation on the application for
insurance.
REQUEST FOR PRODUCTION #1:
2. If your response to Request for Admission #1 contains any denial to any part,
please produce any and all documentation that would tend to support such a
denial.
REQUEST FOR ADMISSION #2:
3. Admit that on the application for insurance, Defendant, ANGEL ENRIQUE CRUZ failed
to disclose that his son, Kevin Migel Gonzalez, resided with him at the policy address
Electronically Received in the Office of the Clerk of the Circuit Court - Flagler County, Florida - 02/15/2021 03:06 PM(22B Plateau LN, Palm Coast, FL 32164).
REQUEST FOR PRODUCTION #2:
4. If your response to Request for Admission #2 contains any denial to any part,
please produce any and all documentation that would tend to support such a
denial.
REQUEST FOR ADMISSION #3:
5. Admit that Kevin Migel Gonzalez resided at the policy address (22B Plateau LN, Palm
Coast, FL 32164) on January 3, 2020.
REQUEST FOR PRODUCTION #3:
6. If your response to Request for Admission #3 contains any denial to any part,
please produce any and all documentation that would tend to support such a
denial.
REQUEST FOR ADMISSION #4:
7. Admit that by failing to disclose that Kevin Migel Gonzalez resided with ANGEL
ENRIQUE CRUZ at the policy address (22B Plateau LN, Palm Coast, FL 32164) on
January 3, 2020, Defendant, ANGEL ENRIQUE CRUZ, made a misrepresentation on
the application for insurance with the Plaintiff, DIRECT GENERAL INSURANCE
COMPANY.
REQUEST FOR PRODUCTION #4:
8. If your response to Request for Admission #4 contains any denial to any part,
please produce any and all documentation that would tend to support such a
denial.
REQUEST FOR ADMISSION #5:
9. Admit that ANGEL ENRIQUE CRUZ signed the subject Application for Insurance
dated January 3, 2020. See a copy of the Application for Insurance, signed by ANGELENRIQUE CRUZ, attached to the Complaint and hereto as Exhibit “C.”
REQUEST FOR PRODUCTION #5:
10. If your response to Request for Admission #5 contains any denial to any part,
please produce any and all documentation that would tend to support such a
denial.
REQUEST FOR ADMISSION #6:
11. Admit that had the Defendant, ANGEL ENRIQUE CRUZ, disclosed on the application
for insurance that Kevin Migel Gonzalez resided with ANGEL ENRIQUE CRUZ at the
policy address (22B Plateau LN, Palm Coast, FL 32164), the Defendant, DIRECT
GENERAL INSURANCE COMPANY would not have issued the policy at the same
premium.
REQUEST FOR PRODUCTION #6:
12. If your response to Request for Admission #6 contains any denial to any part,
please produce any and all documentation that would tend to support such a
denial.
REQUEST FOR ADMISSION #7:
13. Admit that the Defendant is not in possession of evidence to contradict the insured’s
misrepresentation of failing to disclose that Kevin Migel Gonzalez resided with ANGEL
ENRIQUE CRUZ at the policy address (22B Plateau LN, Palm Coast, FL 32164) on
January 3, 2020.
REQUEST FOR PRODUCTION #7:
14. If your response to Request for Admission #7 contains any denial to any part,
please produce any and all documentation that would tend to support such a
denial.CERTIFICATE OF SERVICE
| HEREBY CERTIFY that a true and correct copy of the foregoing was served with the
summons and complaint.
McFARLANE LAW
McFarlane Dolan & Prince
Attorneys for Plaintiff
210 N. University Drive, 6" Floor
Coral Springs, Florida 33071
(954) 340-0005 Broward
(954) 340-0055 Facsimile
PLEADING SERVICE E-MAIL ADDRESS:
pleadingservice@mcfarlanedolaniaw.com
By: _/s/ William J. McFarlane, Ill, Esquire
WILLIAM J. McFARLANE, ESQUIRE
Florida Bar No: 768601
Master Service List
ANGEL ENRIQUE CRUZ VICTOR JOSE PERALTA As The Parent,
22B PLATEAU LN, Natural And Legal Guardian Of JONAELL R.
PALM COAST, FL TORRES, a minor
32164-7439 5411 Hutchinson ST,
Port Orange, FL 32128
VICTOR JOSE PERALTA,
5411 Hutchinson St,
Port Orange, FL 321280000001934473500010193762b7000b0b8002030019000010005
NationalGeneral >» —Flerida
‘Auto, Home & Health insurance
Insurance A
Persona! Auto
Direct General Insurance Company
through MGA Direct General insurance
Agency, Inc.
PO Box 3199
Winston Salem, NC 27102-3199
pplication
FL
[Policy #: 2008776006
Effective Date: 01/03/2020
Time: 11:52 AM
[Amount Enclosed: $197.50 |
Agency Information
Agency Name: Univista Insurance Producer: Lianne Garcia
Agency Number-Producer Code: 9005058 Agency E-Mail: office 1 @univistainsurance.com
Applicant Information
Applicant Name: Angel Enrique Cruz Social Security #:
Affinity Group: AGENCY PLAN CODE
Mailing Address: City: State: Zip:
22B Plateau Ln Palm Coast FL 32164-7439
E-Mail Address: Phone Number: Work Number:
ANGELCS40@YAHOO.ES 305-904-8029
Payment Options
Policy Term # of Payments Payment Type Account #
6 5 Auto Pay - Credit Card XXXXXXXXXXXX6645
Underwriting Information Policy Discount and Surcharge Information
Prior Company Name: Accident Free Claims Free
Other Company Credit Zip Match Discount
Prior Policy Expiration/ Cancellation Date: In Agency Discount
03/22/2020 Multi-Car Discount
Prior BI Limits: Paperless Discount
FL PIP-PD
Vehicle Information
Veh Terr | Year Make Model Serial (VIN) Number Usage Veh Sym
1 69 2010 {TOYT CAMRY BA 4T1BF3EK2AU1 13098 Pleasure/Commute |EG2735
2 69 2014 {FORD F350 SUP 1FT8W3DT3EEB11613 | Pleasure/Commute |E7B2A5
Vehicle Information (continued)
Garaging Address/Zip Code .
Veh (if different from mailing address above) Discounts and Surcharges
1 Airbag Discount
Anti-theft Discount
2 Airbag Discount
Anti-theft Discount
Coverage Information - 2010 TOYT CAMRY BASE/SE/LE/XLE
Coverages Limits/Deductibles Premium
Bodily Injury $10,000 Each Person / $20,000 Each Accident $111.00
Property Damage $10,000 Each Accident $105.00
$10,000 , $1,000 Deductible Per Occurrence -
. . Named Insured and Resident Relatives,
Personal Injury Protection Exclusion of Work Loss Benefit - Named $178.00
Insured and Resident Relatives
EXHIBIT "C"
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Coverage Information - 2014 FORD F350 SUPER DUTY.
Coverages Limits/Deductibles Premium
Bodily Injury $10,000 Each Person / $20,000 Each Accident $122.00
Property Damage $10,000 Each Accident $115.00
$10,000 , $1,000 Deductible Per Occurrence -
Personal Injury Protection Named Insured an o Resident Relatives, $120.00
Insured and Resident Relatives
Other Than Collision $1,000 Deductible $99.00
Collision $1,000 Deductible $198.00
Combined Vehicle Premium: $1,048.00
Additional Charges: $35.00
Total 6 Month Policy Premium: $1,083.00
Driver and Household Member Information
List all persons living in your household who are 15 years of age or older. In addition, list all persons who are
“regular operators” of your vehicle whether living in your household or not.
NOTE: You have a continuing duty during the lite of the issued policy to notify the Company within 30 days from
when any household member turns 15 years of age or obtains a learner's permit or a driver's license, whichever
is earlier. In addition, you have a continuing duty during the life of the policy to notify the Company within 30
days from when a person age 15 years or older becomes a member of your household or regular operator.
Name Drivers License | License Date of Marital | Relationship to
(As shown on license) Number State Driver Status Birth Gender Status Applicant
1 [Angel Enrique Cruz OVOHORKOB Rated Driver [09/08/1970 | Male |Married /Named insured
2 [Mariela Dominguez AR*POPOOKRTS eI Rated Driver 08/17/1980 Female |Married [Spouse
Driver and Household Member Information (continued)
SR-22 Discounts and Surcharges
1 No
2 No
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Applicant's Statement - WARNING: Coverage may be declared null and void if answers are not true and correct.
1. Are any vehicles leased or rented to others? NO
2. Have you failed to disclose any household residents, age 15 and older, whether licensed or NO
not, including but not limited to children away from home or in college?
3. Do any vehicles have a modified or altered engine or suspension? NO
4. Are any non-RV vehicles equipped with cooking equipment, bathroom facilities, or snow NO
removal equipment?
5. Do any vehicles, other than an RV-type towing vehicle, have greater than a one-ton load NO
capacity?
6. Are any vehicles a dump truck, flatbed truck, step van, panel van or stakebed truck or any NO
other commercial auto type?
7. Are any vehicles used as a taxi, limousine or livery? NO
8. Are any vehicles used for delivery, rideshare programs such as Uber and Lyft, the pickup of NO
goods or any other commercial purpose (example’s include, but are not limited to pizza,
newspaper or mail delivery), or emergency response type vehicles or vehicles used for
emergency response purposes?
9. Are any vehicles used to haul explosives? (example: commercial exposure) NO
10. Are any vehicles used for racing? NO
11. Have you failed to disclose any individuals who on a regular basis operate your car, whether NO
residing with you or not?
12. All vehicles, except RV vehicle types, must be garaged in Florida 10 months out of the year. NO
Are any vehicles listed on the application, other than RV vehicle types, garaged in Florida less
than 10 months?
13. Have any applicants had a policy non-renewed by National General within the last 12 months NO
prior to the date of application?
14. Are any non-RV vehicles valued over $100,000 actual cash value? NO
15. Are any vehicles listed on the application “Gray Market’, i.e. not manufactured for original sale NO
in U.S.A?
16. Is the garaging address provided for a PO Box? NO
17. Is the garaging address provided for a business? NO
18. Does any driver have a restricted, suspended, or revoked license? (Except those who require NO
an SR-22 or FR-44 filing).
19. Are any vehicles garaged in the District of Columbia, Hawaii, Massachusetts, Michigan, New NO
Jersey, New York, or anywhere outside of the United States?
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Applicant’s Statement ~ Please read carefully.
| agree all answers to all questions in this Application are true and correct. | understand, recognize, and agree said
answers are given and made for the purpose of inducing the Company to issue the Policy for which | have applied. |
further agree that ALL persons of eligible driving age or permit age or older who live with me, as well as ALL persons
who regularly operate my vehicles and do not reside in my household, are shown above. | agree that my principal
residence and place of vehicle garaging is correctly shown above and that the vehicle is in this state at least 10 months
each year. | understand the Company may rescind this Policy or declare that no coverage will be provided or afforded if
said answers on this Application are false or misleading, and materially affect the risk the Company assumes by issuing
the Policy. In addition, | understand that | have a continuing duty to notify the Company within 30 days of any changes
of: (1) address; (2) garaging location of vehicles; (3) number, type, and use of vehicles to be insured under the Policy.
This includes the use of the vehicle to carry persons or property for compensation or a fee, ride sharing activity, TNC
prearranged trips, personal vehicle sharing program, limousine, or taxi service, livery conveyance, including not-for-hire
livery, or for retail or wholesale delivery, including but not limited to, the pickup, transport, or delivery of magazines,
newspapers, mail, or food. (4) residents of my household of eligible driving age or permit age; (5) driver's license or
permit status (new, revoked, suspended or reinstated) of any resident of my household; (6) operators using any
vehicles to be insured under this Policy; or (7) the marital status of any resident or family member of my household. |
understand the Company may declare that no coverage will be provided or afforded if | do not comply with my
continuing duty of advising the Company of any change as noted above.
MVR & Consumer Report Consent. | understand and agree that in connection with this Application, the Company
may obtain and review vehicle history reports and consumer reports which may include: driver history reports; my credit
report or an insurance score based on the information contained in that credit report; individual background checks on
all listed drivers; or personal or privileged information from third parties. | further understand and agree (1) that the
Company may use a third party in connection with the development of my credit-based insurance score; (2) information
from the consumer reports may be disclosed to affiliated or unaffiliated third parties without my prior permission but
only as permitted or required by law; (3) upon my written request, the Company will inform me if a consumer report was
requested and the name and address of the consumer reporting agency that furnished the report; (4) | may also
request access to and correction of information the Company has collected on me; (5) where permitted by law, the
Company may request and use subsequent consumer reports in updating and renewing any insurance afforded in
connection with this Application; (6) the Company will furnish a more detailed explanation of its information practices
upon my request; and (7) refusal to authorize the Company to obtain a consumer report may give the Company the
right to decline insurance to me.
Applicant Initials: C
1 hereby authorize the Company to obtain history reports on my vehicles and consumer reports on me. | authorize the
Company to obtain from the Department of Highway Safety and Motor Vehicles, Motor Vehicle Reports for me and all
drivers and household members under this policy. | understand this information will be used in rating and/or
underwriting the insurance for which | have applied and any renewal thereafter. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided. | understand this permission will
remain in effect until itis cancelled by me in writing.
Dishonored Payment Acknowledgement. | understand the policy may be rescinded and no coverage provided if my
premium down payment or full payment is paid by check, credit card, or debit card and the bank returns said check
unpaid or fails to honor the credit charge or debit charge in full. Further, if the dishonored check represents the initial
premium payment, the contract shall be void ab initio unless the nonpayment is cured within the earlier of 5 days after
actual notice by certified mail is received by the applicant or 15 days after notice is sent to the applicant by certified mail
or registered mail, and if the contract is void, any premium received by the insurer from a third party shall be refunded
to that party in full.
Fee Acknowledgement. | understand that a fee will be added to each installment after the downpayment. | understand
that fees of $25 for an SR22/FR44 filing, $10 for a late installment or $15 for non-sufficient funds may be assessed and
that those are separate and distinct from the installment fees. | understand that a Policy fee of $25 will assessed at new
business and each renewal. | understand and agree that certain fees are non-refundable and not part of the premium
due. | understand my payments are first applied to the earned fees owed and then to the premium. Installment and
renewal down payments made by draft or check are subject to a non-sufficient funds fee if the financial institution does
not honor the payment for any reason.
Cancellation. All insured requested cancellations will be computed 90% pro-rata. This is the method the Company will
use to compute unearned premium refunds. Cancellations will be mailed or delivered at least 45 days prior to the
effective date of cancellation. At least 10 days’ notice of cancellation will be given for nonpayment. Exception: If the
insured is a service member who cancels because he or she is called to active duty or transferred by the United States
Armed Forces outside the state of Florida, the Company will refund 100 percent of the unearned premium pursuant to
Florida Statute 627.7283.
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Consent to Use Cell Phone Number. | understand and agree that the Company can call or text me at the phone
number | provided to tell me important information about my policy. If | also consented to marketing communication as
set forth in this application, | understand and agree that the Company and its affiliates can use texts, recorded
messages, and/or an automated dialer to call me about insurance quotes, to discuss the status of my policy and about
their other products and services. | understand that | did not have to agree to that in order to purchase my policy and
that | can revoke my consent at any time by notifying the Company in writing.
Producer Acknowledgement. | understand my producer will receive compensation for this Policy in the form of a
commission and may from time to time receive other compensation from the Company based on sales and/or
profitability.
Application Review and Accuracy. | have had the liability coverages and limits available for purchase fully explained
to me and have selected the limits shown on this Application. | have had the different policy coverage levels available
to me fully explained and made an informed decision and have selected the policy coverage level shown on this
Application. | acknowledge and agree to the statements contained within this Application and understand they will
become part of my policy. | also agree that no loss will be covered which occurred on the effective date of this policy
between 12:01 A.M. and the time this Policy became effective. | hereby acknowledge that | have read and understood
all the questions, statements, and information set forth in this Application, including this Applicant's Statement. | hereby
tepresent that my answers and all information, provided by me or on my behalf, contained in this Application is
accurate and complete.
FRAUD WARNING: Per Florida Statute 817.234(1)(b), any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or
misleading information is guilty of a felony of the third degree.
Applicant’s Signature AC Date 01/04 / 2020
PRODUCER’S STATEMENT: PLEASE READ CAREFULLY
| have asked the applicant(s) all questions on this Application and these are the applicant(s) responses. To the best of
my knowledge, all of the information on this Application is true, correct and complete.
PRODUCER'S NAME:
(Please Print) Lianne Garcia
PRODUCER’ :
SIGNATURE: HE Bound Date: 01/03/2020 Time: 11:52 AM
t
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Preview
Filing # 121332494 E-Filed 02/12/2021 03:16:33 PM IN THE CIRCUIT COURT OF THE 774 JUDICIAL CIRCUIT IN AND FOR FLAGLER COUNTY, FLORIDA DIRECT GENERAL INSURANCE COMPANY, Case No.: 2921 CA 000079 Plaintiff, ANGEL ENRIQUE CRUZ, VICTOR JOSE PERALTA, and VICTOR JOSE PERALTA as the Parent, Natural and Legal Guardian of JONAELL R. TORRES, a minor, Defendant(s). PLAINTIFF’S COMBINED FIRST REQUEST FOR ADMISSIONS AND REQUEST FOR PRODUCTION TO DEFENDANT, ANGEL ENRIQUE CRUZ COMES NOW, the Plaintiff, DIRECT GENERAL INSURANCE COMPANY, by and through its undersigned counsel and pursuant to F.R.C.P. 1.370 and 1.350, hereby files this, Plaintiff's Combined First Request for Admissions and Request for Production to the Defendant, ANGEL ENRIQUE CRUZ, directing that the Defendant admit or deny the following allegations and produce all responsive documents, within forty-five (45) days as follows: REQUEST FOR ADMISSION #1: 1. Admit that ANGEL ENRIQUE CRUZ made a misrepresentation on the application for insurance. REQUEST FOR PRODUCTION #1: 2. If your response to Request for Admission #1 contains any denial to any part, please produce any and all documentation that would tend to support such a denial. REQUEST FOR ADMISSION #2: 3. Admit that on the application for insurance, Defendant, ANGEL ENRIQUE CRUZ failed to disclose that his son, Kevin Migel Gonzalez, resided with him at the policy address Electronically Received in the Office of the Clerk of the Circuit Court - Flagler County, Florida - 02/15/2021 03:06 PM(22B Plateau LN, Palm Coast, FL 32164). REQUEST FOR PRODUCTION #2: 4. If your response to Request for Admission #2 contains any denial to any part, please produce any and all documentation that would tend to support such a denial. REQUEST FOR ADMISSION #3: 5. Admit that Kevin Migel Gonzalez resided at the policy address (22B Plateau LN, Palm Coast, FL 32164) on January 3, 2020. REQUEST FOR PRODUCTION #3: 6. If your response to Request for Admission #3 contains any denial to any part, please produce any and all documentation that would tend to support such a denial. REQUEST FOR ADMISSION #4: 7. Admit that by failing to disclose that Kevin Migel Gonzalez resided with ANGEL ENRIQUE CRUZ at the policy address (22B Plateau LN, Palm Coast, FL 32164) on January 3, 2020, Defendant, ANGEL ENRIQUE CRUZ, made a misrepresentation on the application for insurance with the Plaintiff, DIRECT GENERAL INSURANCE COMPANY. REQUEST FOR PRODUCTION #4: 8. If your response to Request for Admission #4 contains any denial to any part, please produce any and all documentation that would tend to support such a denial. REQUEST FOR ADMISSION #5: 9. Admit that ANGEL ENRIQUE CRUZ signed the subject Application for Insurance dated January 3, 2020. See a copy of the Application for Insurance, signed by ANGELENRIQUE CRUZ, attached to the Complaint and hereto as Exhibit “C.” REQUEST FOR PRODUCTION #5: 10. If your response to Request for Admission #5 contains any denial to any part, please produce any and all documentation that would tend to support such a denial. REQUEST FOR ADMISSION #6: 11. Admit that had the Defendant, ANGEL ENRIQUE CRUZ, disclosed on the application for insurance that Kevin Migel Gonzalez resided with ANGEL ENRIQUE CRUZ at the policy address (22B Plateau LN, Palm Coast, FL 32164), the Defendant, DIRECT GENERAL INSURANCE COMPANY would not have issued the policy at the same premium. REQUEST FOR PRODUCTION #6: 12. If your response to Request for Admission #6 contains any denial to any part, please produce any and all documentation that would tend to support such a denial. REQUEST FOR ADMISSION #7: 13. Admit that the Defendant is not in possession of evidence to contradict the insured’s misrepresentation of failing to disclose that Kevin Migel Gonzalez resided with ANGEL ENRIQUE CRUZ at the policy address (22B Plateau LN, Palm Coast, FL 32164) on January 3, 2020. REQUEST FOR PRODUCTION #7: 14. If your response to Request for Admission #7 contains any denial to any part, please produce any and all documentation that would tend to support such a denial.CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing was served with the summons and complaint. McFARLANE LAW McFarlane Dolan & Prince Attorneys for Plaintiff 210 N. University Drive, 6" Floor Coral Springs, Florida 33071 (954) 340-0005 Broward (954) 340-0055 Facsimile PLEADING SERVICE E-MAIL ADDRESS: pleadingservice@mcfarlanedolaniaw.com By: _/s/ William J. McFarlane, Ill, Esquire WILLIAM J. McFARLANE, ESQUIRE Florida Bar No: 768601 Master Service List ANGEL ENRIQUE CRUZ VICTOR JOSE PERALTA As The Parent, 22B PLATEAU LN, Natural And Legal Guardian Of JONAELL R. PALM COAST, FL TORRES, a minor 32164-7439 5411 Hutchinson ST, Port Orange, FL 32128 VICTOR JOSE PERALTA, 5411 Hutchinson St, Port Orange, FL 321280000001934473500010193762b7000b0b8002030019000010005 NationalGeneral >» —Flerida ‘Auto, Home & Health insurance Insurance A Persona! Auto Direct General Insurance Company through MGA Direct General insurance Agency, Inc. PO Box 3199 Winston Salem, NC 27102-3199 pplication FL [Policy #: 2008776006 Effective Date: 01/03/2020 Time: 11:52 AM [Amount Enclosed: $197.50 | Agency Information Agency Name: Univista Insurance Producer: Lianne Garcia Agency Number-Producer Code: 9005058 Agency E-Mail: office 1 @univistainsurance.com Applicant Information Applicant Name: Angel Enrique Cruz Social Security #: Affinity Group: AGENCY PLAN CODE Mailing Address: City: State: Zip: 22B Plateau Ln Palm Coast FL 32164-7439 E-Mail Address: Phone Number: Work Number: ANGELCS40@YAHOO.ES 305-904-8029 Payment Options Policy Term # of Payments Payment Type Account # 6 5 Auto Pay - Credit Card XXXXXXXXXXXX6645 Underwriting Information Policy Discount and Surcharge Information Prior Company Name: Accident Free Claims Free Other Company Credit Zip Match Discount Prior Policy Expiration/ Cancellation Date: In Agency Discount 03/22/2020 Multi-Car Discount Prior BI Limits: Paperless Discount FL PIP-PD Vehicle Information Veh Terr | Year Make Model Serial (VIN) Number Usage Veh Sym 1 69 2010 {TOYT CAMRY BA 4T1BF3EK2AU1 13098 Pleasure/Commute |EG2735 2 69 2014 {FORD F350 SUP 1FT8W3DT3EEB11613 | Pleasure/Commute |E7B2A5 Vehicle Information (continued) Garaging Address/Zip Code . Veh (if different from mailing address above) Discounts and Surcharges 1 Airbag Discount Anti-theft Discount 2 Airbag Discount Anti-theft Discount Coverage Information - 2010 TOYT CAMRY BASE/SE/LE/XLE Coverages Limits/Deductibles Premium Bodily Injury $10,000 Each Person / $20,000 Each Accident $111.00 Property Damage $10,000 Each Accident $105.00 $10,000 , $1,000 Deductible Per Occurrence - . . Named Insured and Resident Relatives, Personal Injury Protection Exclusion of Work Loss Benefit - Named $178.00 Insured and Resident Relatives EXHIBIT "C" 10119FL R6 (07012019) Page 1 of § Doc ID: 3be5e0438e21d5abd2a308ed2667b06548e8d3c600000019384 7360001019374e2b 7000b0L8002030019000020005 Coverage Information - 2014 FORD F350 SUPER DUTY. Coverages Limits/Deductibles Premium Bodily Injury $10,000 Each Person / $20,000 Each Accident $122.00 Property Damage $10,000 Each Accident $115.00 $10,000 , $1,000 Deductible Per Occurrence - Personal Injury Protection Named Insured an o Resident Relatives, $120.00 Insured and Resident Relatives Other Than Collision $1,000 Deductible $99.00 Collision $1,000 Deductible $198.00 Combined Vehicle Premium: $1,048.00 Additional Charges: $35.00 Total 6 Month Policy Premium: $1,083.00 Driver and Household Member Information List all persons living in your household who are 15 years of age or older. In addition, list all persons who are “regular operators” of your vehicle whether living in your household or not. NOTE: You have a continuing duty during the lite of the issued policy to notify the Company within 30 days from when any household member turns 15 years of age or obtains a learner's permit or a driver's license, whichever is earlier. In addition, you have a continuing duty during the life of the policy to notify the Company within 30 days from when a person age 15 years or older becomes a member of your household or regular operator. Name Drivers License | License Date of Marital | Relationship to (As shown on license) Number State Driver Status Birth Gender Status Applicant 1 [Angel Enrique Cruz OVOHORKOB Rated Driver [09/08/1970 | Male |Married /Named insured 2 [Mariela Dominguez AR*POPOOKRTS eI Rated Driver 08/17/1980 Female |Married [Spouse Driver and Household Member Information (continued) SR-22 Discounts and Surcharges 1 No 2 No 10119FL R6 (07012019) Page 2 of 5 Doc ID: 3be5e0438e21d5abd2a308ed2667b06548e8d3c6000000193447370001019374e2b 700060b8002030019000030005 Applicant's Statement - WARNING: Coverage may be declared null and void if answers are not true and correct. 1. Are any vehicles leased or rented to others? NO 2. Have you failed to disclose any household residents, age 15 and older, whether licensed or NO not, including but not limited to children away from home or in college? 3. Do any vehicles have a modified or altered engine or suspension? NO 4. Are any non-RV vehicles equipped with cooking equipment, bathroom facilities, or snow NO removal equipment? 5. Do any vehicles, other than an RV-type towing vehicle, have greater than a one-ton load NO capacity? 6. Are any vehicles a dump truck, flatbed truck, step van, panel van or stakebed truck or any NO other commercial auto type? 7. Are any vehicles used as a taxi, limousine or livery? NO 8. Are any vehicles used for delivery, rideshare programs such as Uber and Lyft, the pickup of NO goods or any other commercial purpose (example’s include, but are not limited to pizza, newspaper or mail delivery), or emergency response type vehicles or vehicles used for emergency response purposes? 9. Are any vehicles used to haul explosives? (example: commercial exposure) NO 10. Are any vehicles used for racing? NO 11. Have you failed to disclose any individuals who on a regular basis operate your car, whether NO residing with you or not? 12. All vehicles, except RV vehicle types, must be garaged in Florida 10 months out of the year. NO Are any vehicles listed on the application, other than RV vehicle types, garaged in Florida less than 10 months? 13. Have any applicants had a policy non-renewed by National General within the last 12 months NO prior to the date of application? 14. Are any non-RV vehicles valued over $100,000 actual cash value? NO 15. Are any vehicles listed on the application “Gray Market’, i.e. not manufactured for original sale NO in U.S.A? 16. Is the garaging address provided for a PO Box? NO 17. Is the garaging address provided for a business? NO 18. Does any driver have a restricted, suspended, or revoked license? (Except those who require NO an SR-22 or FR-44 filing). 19. Are any vehicles garaged in the District of Columbia, Hawaii, Massachusetts, Michigan, New NO Jersey, New York, or anywhere outside of the United States? 10119FL R6 (07012019) Page 3 of § Doc ID: 3be5e0438e21d5abd2a308ed2667b06548e8d3c60000001934473800010193742b 7000b0L400e2030019000040005 Applicant’s Statement ~ Please read carefully. | agree all answers to all questions in this Application are true and correct. | understand, recognize, and agree said answers are given and made for the purpose of inducing the Company to issue the Policy for which | have applied. | further agree that ALL persons of eligible driving age or permit age or older who live with me, as well as ALL persons who regularly operate my vehicles and do not reside in my household, are shown above. | agree that my principal residence and place of vehicle garaging is correctly shown above and that the vehicle is in this state at least 10 months each year. | understand the Company may rescind this Policy or declare that no coverage will be provided or afforded if said answers on this Application are false or misleading, and materially affect the risk the Company assumes by issuing the Policy. In addition, | understand that | have a continuing duty to notify the Company within 30 days of any changes of: (1) address; (2) garaging location of vehicles; (3) number, type, and use of vehicles to be insured under the Policy. This includes the use of the vehicle to carry persons or property for compensation or a fee, ride sharing activity, TNC prearranged trips, personal vehicle sharing program, limousine, or taxi service, livery conveyance, including not-for-hire livery, or for retail or wholesale delivery, including but not limited to, the pickup, transport, or delivery of magazines, newspapers, mail, or food. (4) residents of my household of eligible driving age or permit age; (5) driver's license or permit status (new, revoked, suspended or reinstated) of any resident of my household; (6) operators using any vehicles to be insured under this Policy; or (7) the marital status of any resident or family member of my household. | understand the Company may declare that no coverage will be provided or afforded if | do not comply with my continuing duty of advising the Company of any change as noted above. MVR & Consumer Report Consent. | understand and agree that in connection with this Application, the Company may obtain and review vehicle history reports and consumer reports which may include: driver history reports; my credit report or an insurance score based on the information contained in that credit report; individual background checks on all listed drivers; or personal or privileged information from third parties. | further understand and agree (1) that the Company may use a third party in connection with the development of my credit-based insurance score; (2) information from the consumer reports may be disclosed to affiliated or unaffiliated third parties without my prior permission but only as permitted or required by law; (3) upon my written request, the Company will inform me if a consumer report was requested and the name and address of the consumer reporting agency that furnished the report; (4) | may also request access to and correction of information the Company has collected on me; (5) where permitted by law, the Company may request and use subsequent consumer reports in updating and renewing any insurance afforded in connection with this Application; (6) the Company will furnish a more detailed explanation of its information practices upon my request; and (7) refusal to authorize the Company to obtain a consumer report may give the Company the right to decline insurance to me. Applicant Initials: C 1 hereby authorize the Company to obtain history reports on my vehicles and consumer reports on me. | authorize the Company to obtain from the Department of Highway Safety and Motor Vehicles, Motor Vehicle Reports for me and all drivers and household members under this policy. | understand this information will be used in rating and/or underwriting the insurance for which | have applied and any renewal thereafter. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. | understand this permission will remain in effect until itis cancelled by me in writing. Dishonored Payment Acknowledgement. | understand the policy may be rescinded and no coverage provided if my premium down payment or full payment is paid by check, credit card, or debit card and the bank returns said check unpaid or fails to honor the credit charge or debit charge in full. Further, if the dishonored check represents the initial premium payment, the contract shall be void ab initio unless the nonpayment is cured within the earlier of 5 days after actual notice by certified mail is received by the applicant or 15 days after notice is sent to the applicant by certified mail or registered mail, and if the contract is void, any premium received by the insurer from a third party shall be refunded to that party in full. Fee Acknowledgement. | understand that a fee will be added to each installment after the downpayment. | understand that fees of $25 for an SR22/FR44 filing, $10 for a late installment or $15 for non-sufficient funds may be assessed and that those are separate and distinct from the installment fees. | understand that a Policy fee of $25 will assessed at new business and each renewal. | understand and agree that certain fees are non-refundable and not part of the premium due. | understand my payments are first applied to the earned fees owed and then to the premium. Installment and renewal down payments made by draft or check are subject to a non-sufficient funds fee if the financial institution does not honor the payment for any reason. Cancellation. All insured requested cancellations will be computed 90% pro-rata. This is the method the Company will use to compute unearned premium refunds. Cancellations will be mailed or delivered at least 45 days prior to the effective date of cancellation. At least 10 days’ notice of cancellation will be given for nonpayment. Exception: If the insured is a service member who cancels because he or she is called to active duty or transferred by the United States Armed Forces outside the state of Florida, the Company will refund 100 percent of the unearned premium pursuant to Florida Statute 627.7283. 40119FL Re (07012019) Page 4 of 5 Doc ID: 3be5e0438e21d5abd2a308ed2667b06548e8d3c60000001934473900010193742b 7000b0L8002030019000050005 Consent to Use Cell Phone Number. | understand and agree that the Company can call or text me at the phone number | provided to tell me important information about my policy. If | also consented to marketing communication as set forth in this application, | understand and agree that the Company and its affiliates can use texts, recorded messages, and/or an automated dialer to call me about insurance quotes, to discuss the status of my policy and about their other products and services. | understand that | did not have to agree to that in order to purchase my policy and that | can revoke my consent at any time by notifying the Company in writing. Producer Acknowledgement. | understand my producer will receive compensation for this Policy in the form of a commission and may from time to time receive other compensation from the Company based on sales and/or profitability. Application Review and Accuracy. | have had the liability coverages and limits available for purchase fully explained to me and have selected the limits shown on this Application. | have had the different policy coverage levels available to me fully explained and made an informed decision and have selected the policy coverage level shown on this Application. | acknowledge and agree to the statements contained within this Application and understand they will become part of my policy. | also agree that no loss will be covered which occurred on the effective date of this policy between 12:01 A.M. and the time this Policy became effective. | hereby acknowledge that | have read and understood all the questions, statements, and information set forth in this Application, including this Applicant's Statement. | hereby tepresent that my answers and all information, provided by me or on my behalf, contained in this Application is accurate and complete. FRAUD WARNING: Per Florida Statute 817.234(1)(b), any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree. Applicant’s Signature AC Date 01/04 / 2020 PRODUCER’S STATEMENT: PLEASE READ CAREFULLY | have asked the applicant(s) all questions on this Application and these are the applicant(s) responses. To the best of my knowledge, all of the information on this Application is true, correct and complete. PRODUCER'S NAME: (Please Print) Lianne Garcia PRODUCER’ : SIGNATURE: HE Bound Date: 01/03/2020 Time: 11:52 AM t 10119FL R6 (07012019) Page 5 of § Doc ID: 3be5e0438e21d5abd2a308ed2667b06548e8d3c6