KENTUCKY AUTO APPLICATION

Application # KY0010442174 Date: 08/12/2020

Policy KY01051729A-00 Policy Effective 08/12/2020 at 02:03 P.M.

Garaging Address:
reglafrias@yahoo.com
REGLA FRIAS
5125 QUAIL CT
5125 QUAIL CT
APT 7 APT 7
LOUISVILLE KY 40213 LOUISVILLE KY 40213
DRIVER INFORMATION
DRIVER 1
Name FRIAS, REGLA
DOB 11/27/1979
Sex/Mar F/S
SR-22 N
Vio

VEHICLE INFORMATION
VEHICLE 1
Yr Make 13 HYUNDAI
Model ACCENT GLS
VIN KMHCT4AE0DU390050
Symbol 19
Owner REGLA FRIAS
Lien

COVERAGE AND 6 MONTH PREMIUM INFORMATION

COVERAGES LIMITS OF LIABILITY PREM VEH 1
Bodily Injury Liability $25,000 Each Person/
$50,000 Each Accident $1,071
Property Damage Liability $25,000 Each Accident INCL
Personal Injury Protection Less $250 Deductible $10,000 Each Person $589
VEH 1

Total Premium by Vehicle $1,660

Total Premium All Vehicles $1,660

Application Fee $0.00

Taxes $117.31
Downpayment with Application $295.84
Balance, including installment fees - 5 payments of $309.72
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY FILES AN APPLICATION FOR
INSURANCE CONTAINING STATEMENTS THAT ARE MATERIALLY FALSE OR CONCEALS INFORMATION FOR THE PURPOSE
OF MISLEADING MATERIAL FACTS, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Form KY1000/0116 Please sign at the indicated area on the reverse side of this application and return application to the Company.
 DISCOUNTS AND SURCHARGES
Applicable Discounts ANTI-LOCK BRAKE AIRBAG

Applicable Surcharges

APPLICANT QUESTIONNAIRE Explanation

Y/N
1. Have all residents of your household age 16 years or older been disclosed on this application? Y
2. Have all drivers, such as children away from home or in college or anyone who may operate your
vehicle on a regular or occasional basis, been listed on this application? Y
3. Are all vehicles operated by residents of your household listed on this application? Y
4. Are any of the vehicles for which you are seeking coverage used in the course of business/employment to:
a. conduct consumer oriented sales, service or direct home sales; N
b. visit multiple locations without the transport of clients or patients; N
c. run occasional business related errands; N
d. transport materials, supplies, tools, etc on a regular or occasional basis; or N
e. transport explosives, chemicals or flammable materials? N
5. Are any vehicles for which you are seeking coverage used for delivery purposes (for example: delivery of
N
pizzas, newspapers, food or any other product)?
6. Are any vehicles for which you are seeking coverage used in the course of any insured person’s
employment to transport people? (This does not include car-pooling to and from work but does include
N
transporting people for money.)
N
7. Are any vehicles for which you are seeking coverage used for any other commercial or business purpose?
N
8. Has any driver ever suffered from blackouts, seizures, epilepsy, diabetes or any other physical impairments?
N
9. Does any driver take any regularly prescribed medicine? N
10. Has any driver been involved in an accident or reported a claim to an insurer in the past 5 years? N
11. Is there any existing damage or broken glass to the vehicles listed in this application? N
12. Does any driver drive out of state on a regular basis?

APPLICANT APPROVAL
I hereby apply to the Company for a policy of insurance as set forth in this application on the basis of statements contained herein and do hereby agree to pay any
surcharges applicable under Company rules, which are necessitated by inaccurate statements. I understand that a routine inquiry may be made which will provide
applicable information concerning driving records, loss histories, and other information pertinent to the underwriting of this risk. In connection with this application for
insurance, we may review your credit report or obtain a credit based insurance score, based upon the information contained in that credit report. We may use a
third party in connection with the development of your insurance score. Upon request, the Company will confirm whether a consumer report was requested and
utilized and if so, provide the name and address of the consumer-reporting agency. I understand and agree that my payments may be due earlier if changes are
made to this policy causing my premium to increase. I understand that this policy shall be null and void or cancelled if such information is false or
misleading or would materially affect acceptance of the risk by the Company.
I hereby declare that all persons ages 16 or over who live with me and all other principal, regular, or occasional operators of my vehicles have been reported to the
Company and are listed on this application. I understand and agree that no coverage will be afforded under this policy if the insured vehicles are operated by any
resident of my household, unless that resident is listed as a named insured or is an additional driver on this application or the declarations page, except for a
resident spouse or resident dependents.
I hereby declare that my principal residence/place of vehicle garaging is in Kentucky, eleven (11) or more months a year and that I have disclosed any frequent
travel out of the Commonwealth of Kentucky. I hereby declare that I have reported herein any business use of the vehicles described in this application.
I understand and agree that if I must initiate my policy within 29 days of the date of this application; otherwise, the information contained in this application will
become invalid and I will need to complete another application to initiate a policy with the Company.
I understand and agree that my coverage with Safe Auto Insurance Company is not effective until:
1. Safe Auto Check by Phone: the date and time the checking account information is relayed to the Sales Representative;
2. Western Union or MoneyGram: the date and time printed on the receipt;
3. Credit Card: the date and time the transaction is approved by the creditor;
4. United States Postal Service Mailed Payments with a Legible Postmark: 12:01 A.M. the day after the postmark date shown on the payment envelope;
5. Payments Made by an Overnight Carrier with a Legible Received Date and Time: the day and time the overnight carrier receives the payment;
6. United States Postal Service Mailed Payments with an Illegible Postmark, United States Postal Service Mailed Payments with No Postmark, Payments Made
by an Overnight Carrier with an Illegible Received Date and Time, Payments Made by an Overnight Carrier with No Received Date and Time: 12:01 A.M. the
day the Company receives the payment;
7. Payments Delivered Via a Same Day Carrier: the date and time the Company receives the payment.
8. Payments Made via ACE Check Cashing: Payments are effective the date and time printed on the ACE Check Cashing receipt.
I agree that the coverage afforded me under this policy and the effective dates and times listed above are conditioned on the tender being honored by the financial
institution when presented for payment. If the down payment tender is not honored, the Company shall be deemed not to have accepted the tender, and the policy
shall be voided from inception. I understand that an NSF fee of $25 will be assessed to the balance due on my policy if any tender offered in payment is not
honored. Imposition of such charge shall not deem the Company to have accepted the tender unconditionally. I understand that partial payment is unacceptable
and does not constitute coverage or continuation of coverage under this policy.
I certify that my vehicle does not have any existing physical damage except as indicated in Question 11 in the above questionnaire. I understand that my coverage
under this application will not apply to any currently existing physical damage whether listed above or not.
I certify that I have reported herein any business use or commercial use of the vehicles described in this application. I understand that the Company may refuse to
pay claims arising from the business use of a covered vehicle unless I have previously disclosed such use to the Company.
I understand and agree that if I initiate the cancellation of this policy, all fees will be non-refundable. If the Company initiates the cancellation of my
policy, the application fee will be refunded on a pro-rata basis and all other fees will be non-refundable. Fees may include a $0. application fee, an $13
installment fee (per installment), a $25 NSF fee, a $25 insured request cancellation fee, a $18 late fee, and a $20 SR-22 fee (per SR-22 filing and refiling).
In the event of a loss (including, but not limited to collision, theft, vandalism, hit and run), I agree to report it to the Company as soon as possible. I understand and
agree that failure to comply with this reporting requirement may result in the Company’s refusal to extend coverage for this loss.
I hereby certify that I have read and answered all questions in this application. I have read the insurance fraud statement and all the statements set forth in this
Applicant Approval section. I hereby certify that all information contained in this application is accurate and complete.

APPLICANT SIGNATURE DATE

 REJECTION OF UNINSURED
MOTORISTS COVERAGE
Policy No. KY01051729A-00 Date of Notice 8/12/2020

Named Insured:

REGLA FRIAS
5125 QUAIL CT
APT 7
LOUISVILLE KY 40213

Dear Insured:

In order for us to delete UNINSURED MOTORIST COVERAGE from your policy, please sign the following statement and
return it to us at once. If we do not receive your required signature, this coverage will remain on your policy.

REJECTION OF UNINSURED MOTORIST COVERAGE

I understand and agree Commonwealth of Kentucky requires that Uninsured Motorist Bodily Injury Insurance be afforded
to me under my motor vehicle policy unless I specifically reject this coverage. I understand that rejecting this coverage not
only applies to this policy, but also to all renewals thereof unless I instruct the company to the contrary in writing. By
signing below, I reject this coverage and direct the company to delete this coverage from my policy.

Regla Frias’s signature Date

Please sign above and return to us in the enclosed envelope.

Form KY1130/1008
 Kentucky Certificate of Insurance
Policy No.: KY01051729A-00
Policy Period: From 08/12/2020 02:03 P.M. E. T.
To 02/12/2021 12:01 A.M. E. T.

This certificate is issued as a matter of information only and

confers no rights upon the certificate holder. This certificate does
Regla Frias not amend, extend or alter the coverage, terms, exclusions,
5125 Quail Ct
conditions or other provisions afforded by the policies referenced
Apt 7
Louisville KY 40213 herein.

YEAR MAKE MODEL BODY TYPE VIN

2013 HYUNDAI ACCENT GLS Sedan KMHCT4AE0DU390050

COVERAGES LIMITS OF LIABILITY

Bodily Injury Liability $25,000 Each Person/
$50,000 Each Accident
Property Damage Liability $25,000 Each Accident
Personal Injury Protection Less $250 Deductible $10,000 Each Person

Underwriting Company: Safe Auto Insurance Company

4 Easton Oval
Columbus, Ohio 43219
(614) 231-0200
NAIC # 25405

Date Issued: 08/12/2020 Form KY1185/1013

 Date of Notice 8/12/2020

Policy No. KY01051729A-00

REGLA FRIAS
5125 QUAIL CT
APT 7
LOUISVILLE KY 40213

Please find enclosed the document(s) you have requested. If you have any questions, please
contact our Customer Service Department at 1-800-723-3288.

Thank you for your business!

Safe Auto Insurance Company.

 COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias
Effective Date/Time: 08/12/2020 02:03 P.M.
Expiration Date/Time: 02/12/2021 12:01 A.M.
COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias
Effective Date/Time: 08/12/2020 02:03 P.M.
Expiration Date/Time: 02/12/2021 12:01 A.M.

Cards are no longer valid. Please drive carefully and thank you for the opportunity to serve you.
(1-800-723-3288) to have the insurance policy and insurance cards corrected. If your insurance policy is not in effect, these Automobile Insurance
on the enclosed cards and the VIN on the motor vehicle do not match, you must contact our Customer Service Department at 1-800-SAFE-AUTO
vehicle registration and the VIN on the motor vehicle do not match, you must contact the county clerk to have the registration corrected. If the VIN
compare the VIN appearing on your registration and the VIN listed on your insurance card to the VIN affixed to the vehicle. If the VIN on the motor
the Department of Vehicle Regulation’s database, you may be required to present a copy of this insurance card to the county clerk. Please
You are a valued customer. We are pleased to enclose your replacement temporary Automobile Insurance Cards. If your VIN does not appear in
Card is good through: 10/06/2020 12:01 A.M. Card is good through: 10/06/2020 12:01 A.M.
Policy Number: KY01051729A-00 Policy Number: KY01051729A-00
Policy Type: Personal Policy Type: Personal

Dear Ms. FRIAS:

Year Make Model VIN Year Make Model VIN

LOUISVILLE KY 40213
APT 7
5125 QUAIL CT
REGLA FRIAS
2013 Hyundai Accent Gls KMHCT4AE0DU390050 2013 Hyundai Accent Gls KMHCT4AE0DU390050
Additional Insureds Effective Date/Time Additional Insureds Effective Date/Time

Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288) Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288)
KY1022/1008 KY1022/1008

COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE

VOID VOID VOID
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias VOID VOID VOID
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias
Effective Date/Time: Effective Date/Time:

VOID VOID
Expiration Date/Time: 02/12/2021 12:01 A.M.
Card is good through: 10/06/2020 12:01 A.M.
Policy Number: KY01051729A-00
VOID VOID
Expiration Date/Time: 02/12/2021 12:01 A.M.
Card is good through: 10/06/2020 12:01 A.M.
Policy Number: KY01051729A-00

XX XX
Policy Type: Personal Policy Type: Personal
Year Make Model VIN Year Make Model VIN
20 | 20 |
Additional Insureds Effective Date/Time Additional Insureds Effective Date/Time

VOID VOID VOID VOID

VOID VOID VOID
Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288)
KY1022/1008
VOID VOID VOID
Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288)
KY1022/1008

COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE

VOID VOID VOID
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias VOID VOID VOID
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias
Effective Date/Time: Effective Date/Time:

VOID VOID
Expiration Date/Time: 02/12/2021 12:01 A.M.
VOID VOID
Expiration Date/Time: 02/12/2021 12:01 A.M.

Play it Safe!
Card is good through: 10/06/2020 12:01 A.M. Card is good through: 10/06/2020 12:01 A.M.
Policy Number: KY01051729A-00 Policy Number: KY01051729A-00

KY01051729A-00
Policy Number
XX XX
Policy Type: Personal Policy Type: Personal
Year Make Model VIN Year Make Model VIN
20 20
Additional Insureds Effective Date/Time Additional Insureds Effective Date/Time

VOID VOID VOID VOID

VOID VOID VOID
Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288)
KY1022/1008
VOID VOID VOID
Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288)
KY1022/1008

COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE

VOID VOID VOID
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias
Effective Date/Time:
VOID VOID VOID
Safe Auto Insurance Company NAIC 25405
Named Insured: Regla Frias
Effective Date/Time:

VOID VOID VOID VOID

Expiration Date/Time: 02/12/2021 12:01 A.M. Expiration Date/Time: 02/12/2021 12:01 A.M.
Card is good through: 10/06/2020 12:01 A.M. Card is good through: 10/06/2020 12:01 A.M.
Policy Number: KY01051729A-00 Policy Number: KY01051729A-00
Policy Type: Personal Policy Type: Personal
Year Make Model
20 XX
Additional Insureds
VIN

Effective Date/Time
Year Make Model
20 XX
Additional Insureds
VIN

Effective Date/Time

VOID VOID VOID VOID

VOID VOID VOID
Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288)
KY1022/1008 VOID VOID VOID
Safe Auto Insurance Company 1-800-SAFE-AUTO (1-800-723-3288)
KY1022/1008
 SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288
SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288
SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288
SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288
SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288
SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288
SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288
SAFE AUTO INSURANCE ACCIDENT INFORMATION GUIDE
As a valued customer, Safe Auto offers the following tips in case of an
accident:
1. Stop! Do not leave the accident scene or move your vehicle if possible.
2. Call 911 or the police immediately.
3. Do not admit fault. Do not discuss the details of the accident with
anyone other than the police.
4. Write down the names, addresses, and phone numbers of all people
involved in the accident.
5. Get the license numbers, insurance companies, and policy numbers of all
the drivers involved in the accident.
6. Call SAFE AUTO’S claims department toll free at 1-800-SAFE-AUTO
(1-800-723-3288).
SAFE AUTO INSURANCE COMPANY
4 EASTON OVAL
COLUMBUS, OHIO 43219
1-800-723-3288