Magallanes Broker Agreement

STANDARD BROKER FEE DISCLOSURE

This disclosure was prepared by the California Insurance Commissioner. Please READ IT

CAREFULLY!

I. Do not sign any broker fee agreement unless all of its blank lines and spaces have been filled-in and

you have read the entire document and the agreement carefully.

II. Your insurance broker represents you, the consumer, and is entitled to charge a broker fee if he/she

chooses. This fee is not set by law, and may be negotiable between you and the broker.

III. It is illegal for an insurance broker to charge you a fee for placing coverage solely with the California

Automobile Assigned Risk Plan or the California Fair Plan. Fees may be charged for placement of

other overages.

IV. Broker fees are often non-refundable even if you cancel your coverage. Refer to your broker fee

agreement to see if your broker fee is non-refundable. However, you may be entitled to a full refund of

a broker fee if your broker acted incompetently or dishonestly. Unresolved disputes over non-

refundable broker fees can be forwarded to the Department of Insurance for review.

V. You are entitled to obtain and keep a completed copy of this disclosure and any broker fee agreement

you sign.

VI. Your broker may receive a commission from insurance company (ies) for placing your insurance. this

commission may be paid to your broker by the insurance company (ies) in addition to any broker fee

you pay.

VII. If you will be paying your premium in installments to a finance company, by law you must receive a

copy of a premium finance disclosure and agreement. Be sure to obtain and read those documents

before signing a premium finance agreement. Also, ask the broker if the insurer offers its own

installment payment plan. Insurer installment plans are often cheaper than premium financing through a

separate premium finance company.

VIII. If your broker is placing automobile coverage, your broker must provide you with a copy of the current

Department of Insurance pamphlet Automobile Insurance. If your broker is placing residential

coverage, your broker must provide you with a copy of the current Department of Insurance pamphlet

Residential Insurance. By signing this disclosure, you acknowledge receipt of the appropriate

pamphlet(s).

Client Initials: ____________

EARN $50 IN CASH OR CREDIT TOWARD YOUR MONTHLY PAYMENT

WHEN YOU REFER A FRIEND OR FAMILY MEMBER. JUST MENTION COUPON CODE # 50REF AND YOUR NAME

Cash reward apply for new Policy only. Other restrictions apply.

NEW MILLENNIUM INSURANCE 714-530-1234

jmjm

https://secure.echosign.com/verifier?tx=XNI2ZBS55LXTM48

STANDARD BROKER FEE AGREEMENT

1. The parties to this agreement are _________________________________("CLIENT") and New

Millennium Insurance, California Department of Insurance License # 0H00446 (“BROKER”)

2. CLIENT appoints BROKER as CLIENT'S insurance broker of record.

3. This agreement shall become operative on ____05-18-15______ (date), and shall continue in full force

until terminated by either party.

4. BROKER agrees to represent CLIENT honestly and competently.

5. CLIENT agrees to pay BROKER a broker fee for BROKER'S services. The broker fee

IS / IS NOT refundable (circle one).

Broker Fee Down Payment Down Given Remainder Due Due Date

INCL104 $189.51

$189.51

6. BROKER may in the future charge CLIENT, and CLIENT agrees to pay additional fee(s) for the

services listed below. The additional fees and services are:

Services Fees

Rewrite or Renew policy within 30 days of cancellation $100.00

Adding Another vehicle and/or driver to policy $75.00

Taking and/or making your insurance payment $10.00

7. Following are the nature and amount of all fees known to BROKER that will be charged by persons

other than BROKER or the insurance company in connection with current placement of CLIENT’s

insurance. These fees are not retained by BROKER.

Client Signature _____________________________________________ Date ___05-18-15____

Broker Signature____BRIAN TOYOTA__________________________ Date ___05-18-15____

In case of any questions or problems concerning broker fees or insurance, contact the Department of

Insurance at 1-(800) 927-HELP.

jason magallanes (May 18, 2015)jason magallanes




CREDIT CARD AUTHORIZATION

I, _________________________________, authorize New Millennium Insurance, Inc. to charge the

outstanding balance to my credit card account. I also agree that I will not initiate any dispute on this charge in

the future. Only for the amount of _$189.51_

CREDIT / DEBIT CARD NUMBER: __4833160076543500

EXPIRATION DATE: __01/18 372__

NAME ( AS IT APPEARS ON CARD ): _________________________________________

SIGNATURE REQUIRED: ______________________________________________







POWER OF ATTORNEY

I, _____________________________________, ( Client ) grant New Millennium Insurance Inc. permission

to sign all forms on my behalf of client for new policies, renewal policies and endorsement.

This power of Attorney is to remain in full force and effect until revocation in writing is duly given by me,

_______________________, ( Client) and received by New Millennium Insurance Inc.

Signature __________________________

Date ______________________________

Alliance United Insurance Services

Payment Receipt

Policy # Receipt Date

Insured Confirmation CodeJASON ANSURIO MAGALLANESSANCHEZ

1000 ELM AVE

SEASIDE, CA 93955-4906

AmountBroker L & K Millennium Insurance Inc

12801 Harbor Blvd Suite H-5

GARDEN GROVE, CA 92840

(714) 530-1234 Bus

(714) 741-0676 Fax

Please keep this receipt for your records.

Thank You!

05/18/2015 12:05 PM PT

$85.51

MNS3348370

License No: 0C17987ONB

AU3 CRC705J1812558Z

NB Application

MNS3348370*124*Page 1 of 10AU APP 07/08 – Copyright

Alliance United Insurance Company

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

RECORD MAINTENANCE AMENDMENT - FILE DOCUMENTS

MNS3348370

JASON ANSURIO MAGALLANESSANCHEZ

POLICY #:

INSURED NAME:

5/18/2015 12:05 PM PT

DATE:

L & K Millennium Insurance Inc

BROKER NAME:

BROKER CODE:13018

License No: 0C17987

The documents listed in this form must remain in the policyholder’s file and be maintained by your brokerage for a minimum of five (5) years

from the expiration/cancellation date of this policy.

Please place this form in the file and confirm the documents are included by checking the appropriate box. It is the responsibility of the

producing broker to complete this form and maintain all records in accordance with the Alliance United Record Maintenance Amendment.

A fully and completed signed application including Uninsured Motorist Waiver¨Copy of MVR’s for all listed drivers (unless Alliance United's on-line MVR is used when bridging the application)¨

Copies of Driver’s license or I.D. for all drivers domestic or foreign.¨

Copies of the current registration or sales contract (new or used vehicles) for all vehicles.¨Photos

Will be waived for new and used vehicles that are purchased or leased from a dealer within the last 30 days. A copy of the

sales contract for each vehicle must accompany the application.

Will be required and retained for all vehicles rated as artisan regardless of coverages.

Brokers are responsible for taking two photos showing all sides of the vehicle. The photos must be retained with the application.

¨

Will be waived if a copy of the prior policy is in the file showing Physical Damage coverage for the vehicle(s) with no lapse in

coverage.

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Proof of No-Fault or No-Bodily Injury Accident (if applicable).¨

Signed Driver Exclusion (If applicable).

Proof of Marriage / Proof of identification of an excluded spouse / domestic partner ¨

Proof of identification will be required for the excluded spouse when the system asks for proof at time of upload. We will

require proof the excluded spouse exists and resides with the insured if the registration or other file documents show both

names. Examples of proof are: a photo ID, a bill in the excluded persons name showing the same address as the insured,

a marriage certificate or tax return.

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Registered Owners are listed as a driver or excluded.¨

Copy of the FSC or other rating service quote.¨

Marriage rates apply to domestic partners living in the same household. Domestic Partnership Affidavit is acceptable only

for same sex partners. Same requirements for proof as above.

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THIS COVER PAGE, APPLICATION AND REQUIRED BACKUP ARE FOR ELECTRONIC PURPOSES ONLY.

**** IMPORTANT NOTICE ****

ANY REQUESTS FOR CHANGES, MODIFICATIONS OR AMENDMENTS MUST BE SUBMITTED TO ALLIANCE UNITED SEPARATELY BY

FAX (866) 530-2500 OR E-MAILED TO [email protected] IN ORDER TO BE ACKNOWLEDGED FOR PROCESSING

AND BINDING OF COVERAGE.




Broker Policy #

Broker Name and Address

13018


12801 Harbor Blvd Suite H-5

GARDEN GROVE, CA 92840

(714) 530-1234

MNS3348370NAIC No.

10920

Millennium

Program Name

Applicant Information

Named Insured Mailing Address Effective Date & Time Expiration Date & Time Payment Plan

Garaging Address (If Different)

Home Phone E-mail Address

05/18/2015 12:05 PM PT

(831) 383-2161

Full PayJASON ANSURIO MAGALLANESSANCHEZ

1000 ELM AVE

SEASIDE,CA 93955-4906

[email protected]

Same As Mailing Address

6/18/2015 12:01 AM PT

SRDate

Licensed

StateLic #Marital

StatusGenderDate of

Birth

ApplicantName

Driver Information - Name of all drivers (licensed or permitted) in household

All residents of your household who are 14 years of age and older and any person who regularly drives listed vehicles must be listed as a driver or

excluded.

#

Y7/11/2012CAF7987354SM7/11/1996SelfJASON ANSURIO

MAGALLANESSANCHEZ

1

DescriptionDateDriver #

Accidents and Convictions within the past 36 months

DUI ALCOHOL AND/OR DRUGS (23152A) 1 pts10/31/20141

SUSPENSION (SUSP) 0 pts10/31/20141

REINSTATEMENT (REIN) 0 pts05/18/20151





Not A Valid License (01AU) 0 pts05/18/20151

Vehicle Information

Symbol New/UsedPurchase

Date

UseAnnual

Mileage

VINModelMakeYear#

1996 JEEP GRAND CHER

LAREDO

1J4GZ58Y7TC327925 8500 Pleasure UsedT-16-161




Veh# 1

Limit Prem

Liability - Bodily Injury 15/30 $29.03

Liability - Property

Damage

5,000 $31.34

Total $60.37

Coverage Information - Coverage does not apply unless a premium is indicated

$60.37Total Policy Premium

Total Anti-Fraud Fee $0.14

$5.00SR Filling Fee

$20.00Policy Fee

$85.51

$85.51Down Payment

Total Policy Premium

Additional Comments

New business policy was auto-released via OIS.

-- FSC Quoted Premium : 98.61 User Name : 13018

5/18/2015 12:05:06

PM

-

-

Alliance United Company offers multiple California Personal Auto Programs to eligible insured's. A lower rate or better coverage may be

available to you. If you would like more information about these programs or to obtain a quote, please contact your broker at (714) 530-1234.




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 (1) delete the coverage completely or, (2) to delete the coverage when a motor vehicle is operated by a natural person or persons

designated by name or, (3) agree to provide the coverage in an amount less than that required by subdivision (m) of section 11580.2 of the

Insurance Code but not less than the financial responsibility requirements. Uninsured motorist 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.

This to certify that I understand I have been offered Uninsured Motorist Bodily Injury coverage limits equal to my Bodily Injury coverage limits.

Signature of Named Insured Date

REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE

I REJECT Uninsured Motorist coverage in its entirety.

I elect to delete Uninsured Motorist coverage for Property Damage, but keep Uninsured Motorist coverage for Bodily Injury.

I DO NOT wish to carry Uninsured Motorist Bodily Injury limits equal to my Liability Bodily Injury coverage limits. The reduced limits

of Uninsured Motorist Bodily Injury coverage I request are:

$15,000/$30,000 (initial)

(initial)$25,000/$50,000

(initial)$30,000/$60,000

þ

¨

¨

¨

¨

¨




jason magallanes (May 18, 2015)jason magallanes May 18, 2015


MILLENNIUM APPLICATION DISCLOSURES

BUSINESS USE EXCLUSION

It is agreed that the insurance afforded by this policy does not apply while any motor vehicle listed in the policy is used in the course of

the insured’s business.

Initials:

DISCLOSURE OF HOUSEHOLD MEMBERS AND OTHER DRIVERS

I have listed all residents of my household 14 years old and older and any person(s) who regularly drive listed vehicles on this policy

or excluded them from coverage. I agree to notify the Company of any changes in listed operators. I understand that my failure to notify

the Company of any resident(s) of my household or any person(s) who regularly operate a vehicle shall be considered to be a

misrepresentation and may render my policy null and void.

Initials:

ANNUAL MILEAGE STATEMENT

I acknowledge that the estimated annual vehicle mileage I have provided on this application is true and correct to the best of my

knowledge. I understand that the Company may retroactively adjust my premium if the actual miles driven differ from the estimated

annual vehicle mileage I have provided. If a loss occurs under this policy the Company shall have the option to deduct such additional

premium from any loss settlement. I understand that the Company may request that estimated annual mileage be updated at policy

renewal.

Initials:

Disclosure of Registered Owners and Insurable Interest

I acknowledge and understand that all registered owners and any person with an insurable interest of all vehicles listed on the policy

must be rated as drivers or excluded from the policy. In addition, all registered owners must be listed as additional interest for any

vehicle that has comprehensive and collision coverage. Failure to add the registered owner as an additional interest may result in

comprehensive and collision coverage being denied in case of a claim. I agree to notify the Company of any changes in registered

owners. I understand that my failure to notify the Company shall be considered to be a misrepresentation and may render my policy

null and void.Initials:

STATEMENT OF VEHICLES OWNED (IF SR FILING REQUIRED)

All of the vehicles owned by myself (or my spouse) are insured on the above referenced policy. I understand that it is my responsibility to

add coverage to the policy for any vehicle(s) acquired by me (or my spouse) during the policy term.Initials:




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Notice of Information Practices

I understand that in connection with my request for a premium quotation and application for insurance (1) the insurance company

may obtain consumer reports, which may include a driver history report or vehicle report and I grant them the authority to do so. I

agree that the insurance company may correct my premium if the information obtained from additional sources, including motor

vehicle reports, changes factors which affect the premium; (2) in certain circumstances such information, as well as other personal

privileged information subsequently collected by the insurance company, may be disclosed to third parties without my permission;

(3) upon my written request, within a reasonable time period, the insurance company will inform me whether or not a consumer

report was requested and the name and address of the consumer reporting agency that furnished the report; (4) the insurance

company may request and utilize the subsequent consumer reports in connection with updating and renewing any insurance

afforded in connection with this application; (5) refusal to authorize the insurance company to obtain a consumer report may give the

insurance company the right to decline personal or family insurance to me.

I understand that the coverage selection and limit choices indicated here or in any state supplement will apply to all future policy

renewals, continuations, and changes unless I notify you otherwise in writing.

Applicant's Statement

I have read the above application and any attachments. I declare that the information provided in them is true, complete, and correct

to the best of my knowledge and belief. This information is being offered to the company as an inducement to issue the policy for

which I am applying. I understand that this policy was issued in reliance upon the information provided on this application for

insurance. I agree that the facts and information contained in this insurance application are correct and accurate and that I have not

failed to disclose any material facts relating to the risks insured under this policy. I understand that Alliance United Insurance

Company may void this policy and/or deny coverage for an accident or loss if I, or an insured person, has concealed or

misrepresented any material fact or circumstance, or engaged in fraudulent conduct, at the time this application is made or at any

time during the policy period. The insurance company may void this policy for fraud or misrepresentation even after the occurrence

of an accident or loss.

I further declare that I have not had an accident or theft loss in the last 72 hours. I further understand that coverage does not extend

for accidents occurring in Mexico.

I am aware that pursuant to California Insurance Code Section 1879.2, any person who knowingly presents a false or fraudulent

claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. In addition, any

person who knowingly makes an application for motor vehicle insurance coverage containing any statement that the applicant

resides or is domiciled in this state when, in fact, that applicant resides or is domiciled in a state other than this state, is subject to

criminal and civil penalties.

Signature of Named Insured Date

The broker warrants that the policy provisions and exclusions have been explained to the applicant.

DateBroker Signature




jason magallanes (May 18, 2015)jason magallanes May 18, 2015


CALIFORNIA INSURANCE PROOF CERTIFICATE

Department of Motor Vehicles

P.O. Box 932338

Sacramento, CA 94232-338

The company named below, which is authorized to do business in the State of California, certifies that it has issued to or for the benefit of:

(Please Print or Type)

CHECK ONE BOX ONLY:

NAME DRIVER LICENSE NO. DATE OF BIRTH

ADDRESS CITY STATE ZIP

POLICY NO. EFFECTIVE DATE TIME SUBMITTED

ASSIGNED RISK PLAN NO.

SR-1P ¨ An automobile liability policy as defined in California Vehicle Code Section 16054.

¨

¨þ¨

(P)

(M)

(S)

(U)

(T)

Any other liability policy as defined in California Vehicle Code Section 6431 which meets the requirements of

Section 16056 for vehicles with less than four wheels.

SR-22 A motor vehicle liability policy as defined in California Vehicle Code Section 16450. (BROAD COVERAGE)

Owner’s policy covering all motor vehicles registered to the insured. (Section 16451)

Operator’s policy covering the use by the insured of any motor vehicle not registered to the insured. (Section 16452)

Cancellation or termination of this policy shall be in accordance with Vehicle Code Section 16433.

NAME OF INSURANCE COMPANY

ALLIANCE UNITED INSURANCE COMPANY

DEPT. OF INSURANCE I.D. NO.

4532

ADDRESS OF INSURANCE COMPANY

5300 ADOLFO ROAD STE 200

CITY

CAMARILLO CALIFORNIA

STATE

93012

ZIP

AUTHORIZED REPRESENTATIVE DATE

SR-22/SR-1P (REV. 1/97)

STATE COPY

05/18/2015


SEASIDE

F7987354 7/11/1996

CA 93955-4906

MNS3348370 05/18/2015 12:05 pm

1000 ELM AVE




CALIFORNIA INSURANCE PROOF CERTIFICATE

Department of Motor Vehicles

P.O. Box 932338

Sacramento, CA 94232-338

The company named below, which is authorized to do business in the State of California, certifies that it has issued to or for the benefit of:

(Please Print or Type)

CHECK ONE BOX ONLY:

NAME DRIVER LICENSE NO. DATE OF BIRTH

ADDRESS CITY STATE ZIP

POLICY NO. EFFECTIVE DATE TIME SUBMITTED

ASSIGNED RISK PLAN NO.

SR-1P ¨ An automobile liability policy as defined in California Vehicle Code Section 16054.

¨

¨þ¨

(P)

(M)

(S)

(U)

(T)

Any other liability policy as defined in California Vehicle Code Section 6431 which meets the requirements of

Section 16056 for vehicles with less than four wheels.

SR-22 A motor vehicle liability policy as defined in California Vehicle Code Section 16450. (BROAD COVERAGE)

Owner’s policy covering all motor vehicles registered to the insured. (Section 16451)

Operator’s policy covering the use by the insured of any motor vehicle not registered to the insured. (Section 16452)

Cancellation or termination of this policy shall be in accordance with Vehicle Code Section 16433.

NAME OF INSURANCE COMPANY

ALLIANCE UNITED INSURANCE COMPANY

DEPT. OF INSURANCE I.D. NO.

4532

ADDRESS OF INSURANCE COMPANY

5300 ADOLFO ROAD STE 200

CITY

CAMARILLO CALIFORNIA

STATE

93012

ZIP

AUTHORIZED REPRESENTATIVE DATE

SR-22/SR-1P (REV. 1/97)

PRODUCER COPY

05/18/2015


SEASIDE

F7987354 7/11/1996

CA 93955-4906

MNS3348370 05/18/2015 12:05 pm

1000 ELM AVE




California Insurance ID Card

Effective Date Expiration Date

05/18/2015

If You Are In An Accident

Do not leave the scene.

Call the police to report the accident.

Call at (800) 508-5833.

Do not admit fault. Do not discuss the accident with

anyone except the police and your representative.

1.

2.

3.

4.Policy Number

NAIC # 10920Alliance United Insurance Company

PO Box 6042

Camarillo, CA 93011-6042

Vehicle Information

VIN #ModelMakeYear

1996 JEEP GRAND CHER LAREDO 1J4GZ58Y7TC327925

Year, make, model, and license plate number of all

vehicles involved.

Name of Insurance Company and policy number of

other drivers.

Name, address, driver's license number, and phone

numbers of other drivers and witnesses.

JASON ANSURIO

MAGALLANESSANCHEZ

1000 ELM AVE

SEASIDE,

CA 93955-4906

Named Insured: Exchange information with the other driver. Ask for the

following:

5.

*

*

*Broker:


(714) 530-1234

Named Drivers:

- JASON ANSURIO

MAGALLANESSANCHEZ

MNS3348370 11/18/2015

(ID card valid only if coverage is in-force)




Signature:

Email:

Documents

Magallanes Broker Agreement