method with inserts.pdf

Declaration Page
VEHICLE OWNER
Contract Holder Name: Email: Contract #:
Address: City: State: Zip Code: Phone:
VEHICLE INFORMATION
Year: Make: Model: Current Odometer:
Vehicle Identification Number (17 Digits):
Vehicle Purchase Price:
SELLER INFORMATION
Seller Name:
Seller Code:
Address: City: State: Zip Code: Phone:
LIENHOLDER INFORMATION
Lienholder Name:
Phone:
Address: City: State: Zip Code:
CONTRACT INFORMATION
Contract Purchase Date:
Contract Purchase Price:
CONTRACT COVERAGE & TERM INFORMATION
TERM OF ENROLLMENT: 30 DAYS
GoMonthly Coverage
TERM OF RENEWAL: 30 DAYS
NOTE: This Contract will automatically renew each month unless the Contract Holder cancels benefits or defaults on electronic Contract Renewal Payments voluntarily or involuntarily. This Contract contains
a mandatory waiting period of thirty (30) days from the Contract Purchase Date and one thousand (1,000) miles from the odometer at the time of Contract purchase during which no claims may be
filed. We will attempt to process each Renewal Payment no later than ten (10) calendar days prior to the scheduled Renewal Date to allow time for notification and/or update to Your payment information on file
to be processed. If the Renewal Payment is collected by the Administrator on or before the Renewal Date, the Renewal Term will be in effect: otherwise, the Contract will terminate at the end of the current
Renewal Term.
MANDATORY SURCHARGES
BUSINESS USE
If the above described Vehicle is determined to be used for business purposes and the appropriate surcharge was not selected and paid
for, no coverage applies.
DEDUCTIBLE
The Deductible is the amount that You are required to pay per
repair visit.
ADMINISTRATOR: Dimension Service Corporation, 5500 Frantz Road, Suite 100, Dublin, Ohio 43017, (888) 705-8943
NOTICE: Obligations of the Provider under this Contract are guaranteed by an insurance company. If the Provider (Autoguard Advantage Corporation, 5500 Frantz Road, Suite 100, Dublin,
Ohio 43017, (888) 705-8943) fails to pay or provide service on a claim within sixty (60) days after proof of loss has been filed, the Contract Holder is entitled to make a claim against the
insurance company. The name and address of the Insurance Company is ANV Syndicates Limited, Lloyd’s Underwriting Syndicate Number 5820, 47 Mark Lane, London EC3R 7QQ, United
Kingdom, (888) 705-8941.
The undersigned verify that the information contained herein is true and correct to the best of their knowledge. The undersigned Contract Holder has examined and driven the Vehicle and is
not aware of any mechanical or electrical defect or problem with the Vehicle. The Contract Holder verifies that He/She has read, understands, and will abide by the terms and conditions of
this Contract. No verbal or written representations have been made which may alter the terms and conditions of this Contract. We reserve the right to refuse, cancel, terminate or void any
Contract that does not meet Our underwriting guidelines (except in Arizona). This Contract becomes valid only upon acceptance by the Administrator. Purchase of this Contract is not
necessary to obtain financing for the Vehicle. This is not an insurance policy.
The phone number that I have provided is a mobile number, and I give the company permission to communicate with me via this number.
Purchaser Signature Date Seller Representative Signature Date
NO CLAIMS WILL BE PAID WITHOUT PRIOR AUTHORIZATION! CLAIMS: (888) 705-8943
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