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(& StateFarm° <br />Multiple Line (Renters) Discount <br />ADDITIONAL INFORMATION <br />During the past 10 years has any driver or household member had <br />License suspended, revoked, or refused? <br />No <br />Does any driver have <br />In the last 10 years, a conviction for driving under the influence of alcohol or drugs, <br />or a conviction for vehicular manslaughter while under the influence of alcohol or <br />drugs? <br />No <br />An at -fault accident within the last 6 years? <br />No <br />A minor conviction within the last 6 years? <br />No <br />Primary use of vehicle? <br />Business <br />TERMS AND CONDITIONS <br />State Farm Mutual Automobile Insurance Company of Bloomington, Illinois, hereby binds coverage for the insurance applied for as <br />of the requested effective date for a period of 60 days from such date, subject to all the terms and conditions of the applicable policy <br />and endorsements in current use by such Company. Coverage under this binder will terminate (1) when the Declarations Page of a <br />policy is issued to you or (2) when canceled in accordance with law. <br />By submission of this application, you agree that: (1) you have read this application, (2) your statements on this application are correct, <br />(3) statements made on any other applications on this date for automobile insurance with this company are correct and are made part <br />of this application, (4) you are the sole owner of the described vehicle(s) except as otherwise stated, and (5) the limits and coverages <br />were selected by you. It is further understood and agreed that no insurance is effective under this agreement (a) unless the <br />binder is completed designating the company accepting this application or (b) until the date the policy or binder is issued by <br />the company accepting this application. <br />Consumer reports may be ordered in conjunction with this application. These reports provide information that assists with determining <br />your eligibility for insurance and the price you are charged. <br />State Farm considers the representations you have made about the licensing and driving record(s) to be material. Any <br />concealment or misrepresentation - whether fraudulent, intentional, or unintentional - about your driving record could result <br />in State Farm's re -rating, cancellation, or rescission of your car insurance policy. A rescission could result in your car policy <br />being void from its inception, as if no car policy ever existed. <br />Notice of insurance information collection practices - personal, family, or household insurance transactions: We may collect <br />personal information from persons other than the individual or individuals applying for coverage. Such personal information as well as <br />other personal or privileged information subsequently collected may, in certain circumstances, be disclosed to third parties without your <br />authorization as permitted by law. If you would like additional information about the collection and disclosure of personal information, <br />please contact your State Farm agent. You may also act upon your right to see and correct any personal information in your State <br />Farm files by writing your State Farm agent to request this access. <br />Evidence of a valid U.S. or Canadian license for all drivers in your household must be provided to State Farm within 12 <br />months in order to continue coverage. <br />STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY <br />Policy Number: 583 7885-01555 <br />Named Insured(s): JORGE B MELGOZA, ANNA MELGOZA <br />Effective date: 10-15-2021, Application dateltime:10-15-2021/06:22 PM CDT <br />1 WOU le CA, 12 (rev 10=17) <br />Page 2 of 3 <br />laslr Mmagemmt 1xWelwt <br />lihmemm & APPRovac Or <br />.11, �1, FM� R. VXA44 i <br />Risk Management Analyst <br />