State Farm General Insurance Company Applicant Name: GAUGHEN, PHILLIP R
Binder Effective Date: 10-03-2022
CA Renters
Application / Binder-Receipt 55-EZ-Z442-9
REWRITE of Policy Num: 77-EH-V997-0 From State/Province: CA
APPLICANT: GAUGHEN, PHILLIP R
MAILING ADDRESS: 8956 HARNESS ST APT M3 PROPERTY LOCATION: 8956 HARNESS ST APT M3
SPRING VALLEY, CA 91977-6655 SPRING VALLEY, CA 91977-6655
BILLING:
Put application on SFPP: Yes
COVERAGES / PREMIUM SECTION:
Type: RENTERS Policy Deductible: 500
Policy Coverage Limit Premium Endorsements Limit Premium
Personal Property (Coverage B) 54,800 203.00
Personal Liability (Coverage L) each 300,000 25.00 Back-Up Sewer/Drain - Contents 30% 16,440 14.00
occurrence Only, 30% of Personal Property
Medical Payments (Coverage M) each 1,000
occurrence
Credit Card / Bank Card and Forgery 1,000
Damage to Property of Others (Each 1,000
Occurrence)
Loss of Use 38,360
Loss Settlement Options
Loss Settlement Option - Personal B1 - Limited 35.00
Property Replacement
Cost
Accepted Options Declined Options / Endorsements
Jewelry and Furs 1,000 included Addl Insured - Special Event
Silver/Goldware Theft - Option SG 2,500 included Back-Up Sewer/Drain - Contents
Only, 15% of Personal Property
Business Property - Option BP 1,500 included Business Property - Option BP 2,500
Firearms - Option FA 2,500 included Business Property - Option BP 5,000
Business Pursuits - Option BU
CA Fair Plan Policy Peril Excl
Cyber Event, Identity Restoration, and
Fraud Loss Coverage
Firearms - Option FA 5,000
Home Rental
Incidental Business - Option IO
Jewelry and Furs 2,500 / 5,000
Option JF
Jewelry and Furs 1,500 / 2,500
Option JF
Nurses' Professional Liability
Off Premises Structures
Personal Injury
Rented Personal Property
Silver/Goldware Theft - Option SG 5,000
Silver/Goldware Theft - Option SG 7,500
Silver/Goldware Theft - Option SG 10,000
Waterbed Liability
Discounts / Charges
Claim free discount (24.00)
Home alert (7.00)
Home / Auto discount (39.00)
Intervenor fees 0.38
Total Premium: $207.38
EB 2615 CA.6 Rev. 12-2021 Page 1 of 3
State Farm General Insurance Company Applicant Name: GAUGHEN, PHILLIP R
Binder Effective Date: 10-03-2022
CA Renters
Application / Binder-Receipt 55-EZ-Z442-9
Amount Paid: $0.00
Credit Amount: $0.00
Balance Due: $0.00
APPLICANT(S) ACKNOWLEDGEMENT:
For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to
obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state
prison.
By submission of this application, you agree that: (1) You have read this application, (2) your statements on this application are correct, (3) the coverages,
including options and endorsements, and the amounts of coverage on this application are those chosen by you, and (4) the premium charged must
comply with State Farm's rules and rates and may be revised.
BINDER:
State Farm will provide coverage to the applicant and his or her legal representative on the property described for up to ninety (90) days from the Effective
Date, subject to all terms and conditions of the policy and endorsements for which application has been made. If no Effective Date is indicated, this Binder
does not provide any coverage. This Binder will be void when the declarations page is issued on the policy for which application has been made or when
coverage under this Binder is canceled in accordance with policy provisions.
The premium due State Farm for the coverage provided by this Binder will be the full annual premium for the policy for which application has been made, and
will be pro-rated for the length of time coverage is provided under this Binder.
AGENT INFORMATION:
App date and time: 10-03-2022, 09:25 AM
Agent: Brian Giblin Agent / AFO Code: 8327 / 12FA37 Agent Phone: (858)271-6300
Brian M Giblin Ins Agency Inc
Location Address: 9939 Hibert St Ste 203
San Diego, CA 92131-1031
IMPORTANT NOTICES
REGARDING CLAIM FREE DISCOUNT...
If you are a new applicant, the Claim Free Discount Plan, if in effect in your state, provides a premium discount if you have not had any claims considered
for rating in the five-year period before applying for coverage with State Farm. When rating new applicants, State Farm considers all claims, including
weather-related claims, that resulted in property damage or injury.
If you are a current policyholder and have been insured by State Farm for three or more years, the Claim Free Discount Plan provides a premium discount
if you have not had any claims considered for rating in the most recent three-year period since becoming insured with State Farm. Claims considered for
rating generally include claims resulting in a paid loss and, depending on the Claim Free Discount Plan that applies in your state, may include weather-
related claims. Additionally, if you have been insured with State Farm for less than three years, your claim record in the five-year period before applying for
coverage with State Farm may affect your eligibility for the Claim Free Discount. To find out whether a Claim Free Discount Plan is in effect in your state
and to learn more about the plan and the claims we consider for rating, please contact your State Farm agent.
REGARDING CONSUMER REPORTS...
Consumer reports may be ordered in conjunction with this application. These reports provide information that assists with determining your eligibility for
insurance and the price you are charged. A brochure explaining how State Farm uses consumer reports is available upon your request. For additional
information, please contact your State Farm agent.
REGARDING YOUR COVERAGE AMOUNT...
The State Farm replacement cost is an estimated replacement cost based on general information about your residence. It is developed from models
assuming a variety of contents in a typical unit. The actual cost to replace your personal property may be significantly different. State Farm does not
guarantee that this figure will represent the actual cost to replace your personal property. You are responsible for selecting the appropriate amount of
coverage. Higher coverage amounts may be selected and will result in higher premiums.
REGARDING CLAIM RECORD RATING PLAN...
The longer you are insured with State Farm, and the fewer claims you have, the lower your premium. Our Claim Record Rating Plans determine if a
premium discount or premium increase applies. The premium adjustment is based on the number of years you have been insured with State Farm and on
the number of claims that we consider for rating. Depending on the Claim Record Rating Plan that applies in your state, claims considered for rating
generally include claims with State Farm resulting in a paid loss and may include weather-related claims. And depending on your state's plan and your
tenure with State Farm, any claims with your prior insurer resulting in property damage or injury may also influence your premium. For further information
about whether a Claim Record Rating Plan applies in your state and to learn about the claims we consider for rating, please contact your State Farm agent.
EB 2615 CA.6 Rev. 12-2021 Page 2 of 3
State Farm General Insurance Company Applicant Name: GAUGHEN, PHILLIP R
Binder Effective Date: 10-03-2022
CA Renters
Application / Binder-Receipt 55-EZ-Z442-9
IMPORTANT NOTICES (Continued)
REGARDING PERSONAL, FAMILY OR HOUSEHOLD INSURANCE TRANSACTIONS...
We may collect personal information from persons other than the individual or individuals applying for coverage. Such personal information as well as other
personal or privileged information subsequently collected may, in certain circumstances, be disclosed to third parties without your authorization as
permitted by law. If you would like additional information about the collection and disclosure of personal information, please contact your State Farm agent.
You may also act upon your right to see and correct any personal information in your State Farm files by writing your State Farm agent to request this
access.
EB 2615 CA.6 Rev. 12-2021 Page 3 of 3
