DocuSign Envelope ID: FFB2CAA4-B533-451C-90F8-67E6013B385B
Underwritten by: Bristol West Insurance Company
FAX COVER SHEET
(For Agent Use)
Bristol West Insurance Company
From: 3723844 To:
OPTIONS INSURANCE AGENCY Texas Unit
5900 SUITE 100,
AUSTIN, TX, 78731 Phone # 1-888-888-0080 option 3
Phone: 512-318-2199 Fax # 1-888-888-0070
Fax: 215-839-3948
DATE: 12/08/2024 TIME: 03:28 ET TRANSACTION: New Business
INSURED: RADAVIEN MATLOCK POLICY #: G01 5126753 00 EFF. DATE: 12/08/2024
INCLUDED DOCUMENTS:
Go Paperless – In order to complete enrollment in Go Paperless the customer must complete the following steps within 14 days of policy
upload:
• Open authentication e-mail sent to customer e-mail account.
• Click on authentication link in e-mail.
• Log in and register on foremost.com by creating a username and password. The insured will need to have their policy number
handy.
• Click and accept the Terms and Conditions for Go Paperless.
Please note: It may be necessary for the customer to check the SPAM/JUNK folder of their e-mail account to receive the authentication
e-mail. To avoid future Go Paperless e-mails ending up in the SPAM/JUNK folder the customer may need to adjust their SPAM settings and
should add Bristol West Insurance to their e-mail contact list.
Proof of Prior Insurance:
Your rate has increased because we found prior insurance with a Farmers affiliated company. You can dispute this by uploading the
policy and submitting valid proof of prior insurance with another which may result in an adjustment to your rate. Please see your agent
guide for further details and possible exceptions.
Excluded Driver(s)
Please provide "Proof of Suspended License" or "Proof of Other Insurance".
MINIMUM PAGES INCLUDING THIS COVER: _# of docs + 1_
DocuSign Envelope ID: FFB2CAA4-B533-451C-90F8-67E6013B385B
Underwritten by:
BRISTOL WEST INSURANCE COMPANY (33)
5000 QUORUM DR, STE 410, DALLAS, TX 75254 POLICY NUMBER: G01 5126753 00
Rates Effective Date 07/29/2021
NAMED INSURED PRODUCER INFORMATION
RADAVIEN MATLOCK OPTIONS INSURANCE AGENCY
120 N HAWTHORN ST 5900 SUITE 100,
CARTHAGE, TX, 75633 AUSTIN, TX, 78731
email address: umiharyadi17@gmail.com
Home: Producer Code: 3723844
Work: Truck Driver
*Must reside in Pennsylvania at least 10 months during the year
POLICY INFORMATION
EFFECTIVE DATE: 12/08/2024* TOTAL PREMIUM: $1,386.00
EXPIRATION DATE: 06/08/2025 DOWN PAYMENT: $1,396.00
UPLOAD DATE: 12/08/2025 PAYMENT RECEIVED: $1,396.00
* later of 12:01 am or the time application is executed
DRIVER AND RESIDENT INFORMATION
The applicant, spouse and all household residents 15 years of age or older, all operators of the vehicles described in this application and all
children who live away from home who drive these vehicles, even occasionally, are listed below.
# NAME DOB SEX Marital Status License Status Relationship Driver Status
1 RADAVIEN MATLOCK 1971 M S Valid TDL Insured Rated
VEHICLE INFORMATION
AT LEAST ONE VEHICLE MUST BE GARAGED IN TEXAS 10 MONTHS OF THE YEAR
# YEAR/MAKE/MODEL VIN USE GARAGING ZIP
1 2010 CHEV TAHOE C1500 LTZ UT 1GNUCCE00AR109579 Pleasure 17013
2 2013 GMC SIERRA C1500 SLE PK 3GTP1VE09DG109284 Pleasure 17013
3 2014 FORD F250 SUPER DUTY PK 1FT7W2BT0EEA14300 Pleasure 17013
AUTO INSURANCE HISTORY
Bristol West, policy number: 33G011080698 Continually insured for less than 12 months
No prior insurance
PREMIUM DISCOUNTS
Paid In Full, Go Paperless,
App 001 (05/19)
Date: 12/08/2021 Page 2
DocuSign Envelope ID: FFB2CAA4-B533-451C-90F8-67E6013B385B
Underwritten by: Bristol West Insurance Company
PREMIUM BY VEHICLE
Vehicle 1: 2010 CHEV TAHOE C1500 LTZ UT
VIN: 1GNUCCE00AR109579
Discounts applied to Vehicle: Double Air Bag
Coverage Limit Per Person Limit Per Accident Deductible Premium
LIMITED TORT
BODILY INJURY LIABILITY $15,000 $30,000 $75.00
PROPERTY DAMAGE LIABILITY $5,000 $122.00
MEDICAL EXPENSE $5,000 $33.00
UNINSURED MOTORISTS Rejected
UNDERINSURED MOTORISTS Rejected
COMPREHENSIVE $1000 $28.00
COLLISION $1000 $163.00
RENTAL REIMBURSEMENT $12.00
( $20 PER DAY / 30 DAYS MAXIMUM)
Total Premium for 2010 CHEV TAHOE C1500 LTZ UT $433.00
Vehicle 2: 2013 GMC SIERRA C1500 SLE PK
VIN: 3GTP1VE09DG109284
Discounts applied to Vehicle: Double Air Bag
Coverage Limit Per Person Limit Per Accident Deductible Premium
LIMITED TORT
BODILY INJURY LIABILITY $15,000 $30,000 $75.00
PROPERTY DAMAGE LIABILITY $5,000 $122.00
MEDICAL EXPENSE $5,000 $33.00
UNINSURED MOTORISTS Rejected
UNDERINSURED MOTORISTS Rejected
COMPREHENSIVE $1000 $28.00
COLLISION $1000 $163.00
RENTAL REIMBURSEMENT $12.00
( $20 PER DAY / 30 DAYS MAXIMUM)
Total Premium for 2013 GMC SIERRA C1500 SLE PK $433.00
App 001 (05/19)
Date: 12/08/2021 Page 3
DocuSign Envelope ID: FFB2CAA4-B533-451C-90F8-67E6013B385B
Vehicle 1: 2014 FORD F250 SUPER DUTY PK
VIN: 1FT7W2BT0EEA14300
Discounts applied to Vehicle: Double Air Bag
Coverage Limit Per Person Limit Per Accident Deductible Premium
LIMITED TORT
BODILY INJURY LIABILITY $15,000 $30,000 $75.00
PROPERTY DAMAGE LIABILITY $5,000 $122.00
MEDICAL EXPENSE $5,000 $33.00
UNINSURED MOTORISTS Rejected
UNDERINSURED MOTORISTS Rejected
COMPREHENSIVE $1000 $28.00
COLLISION $1000 $163.00
RENTAL REIMBURSEMENT $12.00
( $20 PER DAY / 30 DAYS MAXIMUM)
Total Premium for 2013 GMC SIERRA C1500 SLE PK $433.00
TOT AL POLICY PREMIUM
Vehicle Subtotal (all vehicles) $1,299.00
Policy Fee $87.00
Grand Total (Semi-Annual) $1,386.00
Service Fees Not included in Total Premium: Excluded Driver Fee: $10.00
App 001 (05/19)
Date: 12/08/2021 Page 4
DocuSign Envelope ID: FFB2CAA4-B533-451C-90F8-67E6013B385B
App 001 (05/19)
Date: 12/08/2021 Page 5
