PO Box 3199 ● Winston Salem NC 27102-3199

Personal Auto Policy: 2029846677 Effective Date: 07/08/2025

Roadside Assistance: 2029846678

Insured Name: David Houser Insured’s Home Phone: 980-429-8331

Insured Address: 189 Cedar Grove Church Rd Insured’s Work Phone:
Vale, NC 28168

AGENCY “TO DO” LIST

The following items must be retained in your customer file. Do not send these items to National General
Insurance:

 Signed Automatic Payments Authorization Form

 Signed Online Policy Posting Consent Form Required

 Signed Application

 Signed Pay Plan Authorization

 Signed Roadside Application

 Signed Benefits and Acknowledgement for Roadside Form needed

Thank you for choosing National General Insurance!

07400 (08012017)
 PO Box 3199 ● Winston Salem NC 27102-3199 Date: 07/08/2025
Personal Auto Policy: 2029846677
Roadside Assistance: 2029846678

DAVID HOUSER Named Insured:

CRISTY L HOUSER David Houser
189 CEDAR GROVE CHURCH RD Cristy L Houser
VALE NC 28168 Policy Period: 07/08/2025 - 07/08/2026

Agent:
Guided Insurance Solutions
4211 W Boy Scout Blvd Ste 165
Tampa FL 33607
(877) 611-3030

RECEIPT & PAYMENT SCHEDULE

Payment Received: $296.41
Date Payment Received: 7/8/2025 11:30:00 AM
Payment Confirmation Number: ccCA40CE

Payment Received By:

Payment Schedule Payment Amount

08/08/2025 $264.18
09/08/2025 $264.17
10/08/2025 $264.17
11/10/2025 $264.17
12/08/2025 $264.17
01/08/2026 $264.17
02/09/2026 $264.17
03/09/2026 $264.17
04/08/2026 $264.17
05/08/2026 $264.17
06/08/2026 $264.17

The above installments may not reflect billing changes made to your policy.

To get an electronic copy of your North Carolina Private Passenger Auto Policy go to
www.nationalgeneral.com/NorthCarolina/PPA/Policy

Thank you for choosing National General Insurance!

Email: Service@NGIC.com  Fax: 1-877-849-9022  Phone: (833) 306-5064

Visit us at www.MyNatGenPolicy.com
07178 (10012017)
 PO Box 3199 ● Winston Salem NC 27102-3199

DAVID HOUSER
CRISTY L HOUSER
189 CEDAR GROVE CHURCH RD
VALE NC 28168

Welcome! Thank you for choosing us to protect your assets!

As your insurance agency, we’re excited to provide you with the additional peace of mind of having a policy
with National General Insurance. You can file a claim or manage your policy online 24/7, every day of the year.
If you ever need help with your policy — whether you have questions about a payment or you want to explore
coverage options — do not hesitate to give us a call!
Here’s how you can reach us:
Guided Insurance Solutions
4211 W Boy Scout Blvd Ste 165
Tampa FL 33607
(877) 611-3030
(813) 782-3555
ClientCare.MIS@baldwin.com
Complete your registration for paperless billing and manage your policy online!
We just need you to do one more thing… Check your inbox for an email that will allow you to complete
registration for paperless billing. You can also register by going to www.MyNatGenPolicy.com. That’s all
there is to it! As long as you complete the registration, you’ll receive important notifications about your policy at
the email address you provided instead of through regular mail. You’ll have immediate, on-demand access to
view and print all your important policy documents — like insurance ID cards — and manage your policy
online.
World-Class Claim Service
We’re happy to tell you that as a policyholder with National General Insurance you can expect world-class
claim service. And, collision repairs made at any of their Gold Medal Repair Shops are backed by a lifetime
guarantee. You can report a claim at any time by calling 1-800-468-3466. A claims professional will be there to
take your call and help you get back on the road as quickly as possible.
Customer Service
You can always call the customer service department at National General Insurance if you need help with
anything relating to your policy. Call them at (833) 306-5064.

Email: Service@NGIC.com  Fax: 1-877-849-9022  Phone: (833) 306-5064

Visit us at www.MyNatGenPolicy.com
10994 (03012019)
Dear Customer,

Enjoy the flexibility of on-demand access to your policy documents and Go Paperless! Just
follow the steps below to verify your policy information:
1. Check your email houserd74@icloud.com for a Go Paperless reminder
2. Click on the link and enter your policy number and date of birth
3. Establish a login ID and password
4. Accept the terms and conditions
That’s all there is to it! Once you complete your registration, you will have immediate, online
access to all of your policy documents including ID cards, declarations pages, monthly bills and
more!

Take advantage of these online benefits when you Go Paperless!

• Get instant, on-demand access to policy documents — like your ID cards

• Make payments securely, check your balance and view payment history
• No paper, no clutter — with easy access to all your policy documents in one location
• Report a claim!

11153 (08012017)
 North Carolina Integon General Insurance
Personal Auto &
Recreational Vehicle
Insurance Application
Corporation

PO Box 3199
NC
Winston Salem NC 27102-3199
0000006027808400010602706870006997002030019000010005

Policy #: 2029846677 Effective Date: 07/08/2025 Time: 11:30 AM Amount Enclosed: $296.41

Agency Information
Agency Name: Guided Insurance Solutions Producer: Jamari Thorne
Agency Number-Producer Code: 9034004 Agency E-Mail: ClientCare.MIS@baldwin.com

Applicant Information
Applicant Name: David Houser Social Security #:
Affinity Group: Large National Accounts
Mailing Address: City: State: Zip:
189 Cedar Grove Church Rd Vale NC 28168

E-Mail Address: Phone Number: Work Number:

houserd74@icloud.com 980-429-8331
Payment Options
Policy Term # of Payments Payment Type Account #
12 11 Auto Pay - Credit Card XXXXXXXXXXXX6267
Underwriting Information Policy Discount and Surcharge Information
Prior Company Name: Credit Zip Match Discount
GEICO Multi Car Discount
Prior Policy Expiration/ Cancellation Date: Paperless Discount
01/04/2026
Prior BI Limits:
$50,000 / $100,000
Legacy Family Customer: Homeowner:
No No
Vehicle Information
Veh Terr Year Make Model Serial (VIN) Number Usage Veh Sym
To/From Work or
1 470 2020 DODG DURANGO 1C4RDJAG7LC249282 School Less Than HA2522
10 Miles - 1B
To/From Work or
2 470 1997 TOYT CAMRY CE 4T1BF22K3VU913459 School Less Than PQ1433
10 Miles - 1B
Loss Payee, Additional Interest and Insured Lessor Information
Veh Type Name Address—Street, City, State, Zip
1 Loss Payee Carmax Auto Finance PO Box 440609, Kennesaw, GA 30160-9511

10119NC R6 (04012021)
 Coverage Information - 2020 DODG DURANGO SXT
Coverages Limits/Deductibles Premium
Bodily Injury $50,000 Each Person / $100,000 Each Accident $298.93
Property Damage $50,000 Each Accident $334.92
Uninsured / Underinsured Motorist Bodily Injury $50,000 Each Person / $100,000 Each Accident $136.00
Uninsured Motorist Property Damage $50,000 Each Accident $7.00
0000006027808500010602706870006997002030019000020005

Other Than Collision $1,000 Deductible $297.00

Collision $1,000 Deductible $761.00
Coverage Information - 1997 TOYT CAMRY CE/LE/XLE
Coverages Limits/Deductibles Premium
Bodily Injury $50,000 Each Person / $100,000 Each Accident $498.72
Property Damage $50,000 Each Accident $560.72
Uninsured / Underinsured Motorist Bodily Injury $50,000 Each Person / $100,000 Each Accident No Cost
Uninsured Motorist Property Damage $50,000 Each Accident No Cost

Combined Vehicle Premium: $2,894.29

Additional Charges: $40.00
Total 12 Month Policy Premium: $2,934.29

Driver and Household Member Information – List all persons of eligible driving age or permit age.
Name Drivers License License Date of Marital Relationship to
Driver Status Gender
(As shown on license) Number State Birth Status Applicant
XXXXXXXX540
1 David Houser NC Rated Driver 02/20/1974 Male Married Named Insured
3
XXXXXXXX838
2 Julia Payson Houser NC Rated Driver 10/16/2002 Female Single Child
6
XXXXXXXX661
3 Carson Kensley Houser NC Rated Driver 09/16/1999 Female Single Child
1
XXXXXXXX543
4 Cristy L Houser NC Rated Driver 12/14/1976 Female Married Named Insured
0
Driver and Household Member Information (continued)
SR-22 Discounts and Surcharges
1 No
2 No
3 No
4 No
Accidents, Violations and Nonchargeable Incidents – All accidents are chargeable, unless proof of not at fault is
furnished
Violation/ List Date and Details of All Accidents, Coverage and
Driver Name Conviction/ Violations and Convictions During Amount Paid for Disputed Points
Accident Date Previous 60 months Damages
At-Fault PD $2,301 - $3,849 (no BI or
Julia Payson Houser 02/04/2024 No 2
BI less than $1,801) = 2 pts

10119NC R6 (04012021)
 Applicant’s Statement
Is any vehicle leased or rented to others? NO
Are any vehicles regularly available to non-listed operators? NO
Do any vehicles have a modified or altered engine or suspension that is lifted more than 6 NO
inches?
Are any non-RV vehicles equipped with cooking equipment, bathroom facilities, or snow removal NO
0000006027808600010602706870006997002030019000030005

equipment?
Do any vehicles, other than an RV-type towing vehicle, have greater than a one-ton load NO
capacity?
Are any vehicles a dump truck, flatbed truck, or stakebed truck? NO
Are any vehicles used as a taxi or limousine? NO
Are any vehicles used for delivery or pick up of goods? NO
Are any vehicles used for livery? NO
Are any vehicles used for emergency purposes? NO
Are any vehicles used for racing? NO
Are any vehicles used to haul explosives, magazines, newspapers, or mail? NO
Consent for Policy and Driver service calls and texts? YES

10119NC R6 (04012021)
 Applicant’s Statement – Please read carefully.
I agree all answers to all questions in this Application are true and correct. I understand, recognize, and agree said
answers are given and made for the purpose of binding coverage for which I have applied. I further agree that ALL
persons of eligible driving age or permit age who live with me, as well as ALL operators who regularly operate my
vehicles and do not reside in my household, are shown above. I agree that my principal residence and place of vehicle
garaging is correctly shown above and is in the state for which I am applying for insurance at least 6 months each year.
I understand the Company may rescind or reform all coverages under this policy except such insurance coverage as
required by the financial responsibility laws of North Carolina if said answers on this Application are false or misleading,
0000006027808700010602706870006997002030019000040005

and materially affect the risk the Company assumes by issuing the policy. In addition, I understand that I have a
continuing duty to notify the Company of any changes of: (1) address; (2) garaging location of vehicles; (3) number,
type, and use of vehicles to be insured under the Policy. This includes the use of the vehicle to carry persons or
property for compensation or a fee, ride sharing activity, TNC prearranged trips, personal vehicle sharing program,
limousine, or taxi service, livery conveyance, including not-for-hire livery, or for retail or wholesale delivery, including
but not limited to, the pickup, transport, or delivery of magazines, newspapers, mail, or food.(4) residents of my
household of eligible driving age or permit age; (5) driver’s license or permit status (new, revoked, suspended or
reinstated) of any resident of my household; (6) operators using any vehicles to be insured under the Policy; or (7) the
marital status of any resident or family member of my household. I understand the Company may rescind or reform all
coverages under this policy except such insurance coverage as required by the financial responsibility laws of North
Carolina if I do not comply with my continuing duty of advising the Company of any change as noted above.
I understand and agree that in connection with this Application the Company may obtain and review vehicle history
reports and consumer reports which may include: driver history reports, my credit report, or an insurance score based
on the information contained in that credit report; individual background checks on all listed drivers; or personal or
privileged information from third parties. I further understand and agree (1) that the Company may use a third party in
connection with the development of my credit-based insurance score; (2) information from the consumer reports may
be disclosed to affiliated or unaffiliated third parties without my prior permission but only as permitted or required by
law; (3) upon my written request, the Company will inform me if a consumer report was requested and the name and
address of the consumer reporting agency that furnished the report; (4) I may also request access to and correction of
information the Company has collected on me; (5) where permitted by law, the Company may request and use
subsequent consumer reports in updating and renewing any insurance afforded in connection with this Application; (6)
the Company will furnish a more detailed explanation of its information practices upon my request; and (7) refusal to
authorize the Company to obtain a consumer report may give the Company the right to decline insurance to me.
I hereby authorize the Company to obtain history reports on my vehicles and consumer reports on me. I hereby certify
that the named drivers under this policy have authorized me to consent on their behalf for the insurer to obtain
consumer reports for rating and/or underwriting. This certification of authorization would apply to any drivers named
under the policy who, reside in the household or have regular and frequent access to the vehicle(s) to be insured
herein, for the life of the policy and it is my duty to inform them of this practice.
I have had the liability and uninsured/underinsured motorists coverages and limits available for the purchase fully
explained to me and have selected the limits shown on the Application. I have had the different policy coverage levels
available to me fully explained. I made an informed decision and have selected the policy coverage level shown on the
application.
I understand the policy may be rescinded and no coverage provided if my initial premium payment or full payment is
paid by check, credit card, or debit card or other remittance and the bank returns said check unpaid or fails to honor the
credit charge or debit charge, or other remittance in full. I understand there may be a $20 processing fee imposed on
any returned checks. I understand that each installment payment, regardless of payment method will include a $3
installment fee and I understand processing fees may be included with my down payment and installment payments. I
understand my payments are first applied to the fees owed and then to the premium. I understand and agree that
certain fees are non-refundable and not part of the premium due.
I acknowledge and agree to the statements contained within this application and they will become part of my policy. I
also agree that no loss will be covered which occurred on the effective date of the Policy between 12:01 A.M. and the
time the Policy became effective.
Consent to Use Cell Phone Number. By providing phone number(s) for myself and any other individual(s) I have
listed on this application, I acknowledge and confirm that I, and each such individual, expressly consent to the
Company making policy related service calls and/or texts to our respective numbers. Each person has authorized me to
give their consent to the Company. I agree that I have or will notify them that I have communicated their consent and
that the Company may be calling or texting them as described. If I also consented to marketing communication as set
forth in this application, I understand and agree that the Company and its affiliates can use texts, recorded messages,
and/or an automated dialer to call me about insurance quotes, to discuss the status of my policy and about their other
products and services. I understand that I did not have to agree to that in order to purchase my policy and that I can
revoke my consent at any time by notifying the Company in writing.

10119NC R6 (04012021)
 I understand my producer will receive compensation for this policy in the form of a commission and may from time to
time receive other compensation from the Company based on sales and/or profitability.
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a Class 1 or
Class 3 misdemeanor.

Applicant’s Signature <PrimarySign> Date <PrimaryDate>

07/08/2025
0000006027808800010602706870006997002030019000050005

Applicant’s Signature <CoNamedInsSign> Date <CoNamedInsDate>

07/08/2025

Applicant’s Statement – Continued

In the event I elect to pay my premium in installments through a company sponsored pay plan, I understand a fully
earned policy fee up to $50 will apply to my policy. I also understand and agree that in the event an installment is
received after the due date, up to a $15 late fee will apply. If my policy cancels and the company agrees to reinstate my
coverage, I will be charged a reinstatement fee up to $30. I understand and agree that these fees apply to this and all
subsequent policy terms.

Applicant’s Signature <PrimarySign> Date <PrimaryDate>

07/08/2025

Applicant’s Signature <CoNamedInsSign> Date <CoNamedInsDate>

PRODUCER’S STATEMENT: PLEASE READ CAREFULLY

I have asked the applicant(s) all questions on this Application and these are the applicant(s) responses. To the best of
my knowledge, all of the information on this Application is true, correct and complete.
PRODUCER’S NAME:
(Please Print) Jamari Thorne
PRODUCER’S
SIGNATURE: <ESigAgent> Bound Date: 07/08/2025 Time: 11:30 AM

10119NC R6 (04012021)
 NC Online Policy Posting Consent
0000006027464900010602706870003566002030019000010001

Your NC Personal Auto Policy is available online. View, print and save your NC Personal Auto Policy
by going to our website: www.nationalgeneral.com/NorthCarolina/PPA/Policy. The applicable forms
relating to your policy are also listed in the “Forms and Endorsements” section on your Declarations
Page.

Your consent to electronic delivery of your NC Personal Auto Policy may be changed at any time by notifying
us in writing, by calling at (833) 306-5064 or by e-mail at Service@NGIC.com. After we have processed your
request, all future copies of your NC Personal Auto Policy will be delivered to you in paper form at your mailing
address provided.

To view or download your NC Personal Auto Policy, the Site requires access to the Internet and is designed for
use with Internet Explorer version 6.0 or later and Mozilla Firefox version 2.0.0.3 or later. Please be sure that
your internet browser is set to allow for pop-ups to be displayed and that “cookies” are enabled. You will be
able to print copies of your NC Personal Auto policy, which will be available in PDF format. If you need a
program to view the PDFs, you can download Adobe Reader for free at www.adobe.com.

Should any technological change or upgrade be made that will affect your ability to access your NC Personal
Auto Policy, we will notify you and remind you of your right to withdraw your consent to receive your NC
Personal Auto Policy electronically and to receive paper records instead.

I have read and understand the above notice and have elected to receive my NC Personal Auto
Policy electronically by viewing it on your website rather than by receiving it in paper form.

Named Insured David Houser Policy Number 2029846677

Signature of Applicant <PrimarySign> Date <PrimaryDate>

07/08/2025

11467 (02012015)
 PO Box 3199 ● Winston Salem NC 27102-3199 Personal Auto Policy: 2029846677
Roadside Assistance: 2029846678

DAVID HOUSER
0000006028049900010602706870009416002030019000010001

189 CEDAR GROVE CHURCH RD

VALE NC 28168 Phone:1-833-306-5064
Fax:1-877-849-9022

Electronic Funds Transfer (EFT)/Automatic Payments Deduction

Authorization Agreement
for Integon General Insurance Corporation

Please verify that the information below is correct.

Named Insured:
David Houser
Payment Date: Account Type:
Day 8 of the Month MasterCard

Account No.: Expiration Date: CVV No.: Account Billing Zip Code:
XXXXXXXXXXXX6267 06/2028 XXX 28168

Account Holder’s Name:

CRISTY L HOUSER Cristy l houser

Account Holder’s Authorized Signature: Date:

<PrimarySign> <PrimaryDate>
07/08/2025

I attest that I am the owner and/or authorized signer for the account designated above, hereafter the “Account”. I hereby
authorize Integon General Insurance Corporation and any of its affiliates, to hereafter as each referred “the Company”, to
initiate recurring payment deductions from the Account in accordance this Authorization. I acknowledge the Company is
providing me an Automatic Payments Schedule which is incorporated here by reference. I understand that the Company
will not send me a bill prior to the scheduled deduction. I understand and agree that if a transaction is delayed for any
reason, it will be processed as soon as practical which may be after the scheduled date. I authorize the financial
institution identified by the routing or card account number to honor all entries to the Account by the Company.
I agree that if my initial payment deduction is not honored when presented for payment, the policy shall be deemed void
from its inception, if allowed by law. If an installment or renewal payment is dishonored for any reason, I agree that the
Company may at its discretion attempt to process the transaction again. I agree that an NSF charge may be assessed
for each dishonored transaction. If a transaction is dishonored, I also understand that my policy may cancel or
expire for nonpayment, the Company may remove me from the automatic payment plan, and I remain
responsible for any amounts I owe to the Company.
I acknowledge that this agreement authorizes the Company to adjust the recurring payment deductions to reflect any
changes to the policy or other products included on my payment plan. If a change to my installment amount occurs
during the policy term, the Company will notify me at least 10 days prior to making any deductions from the Account. I
understand that if a correction of any entry is necessary, it may involve an adjustment to the Account.
This authorization applies to the policy listed above and any continuation, renewal, including by affiliate transfer, or
change to the policy. This authorization will remain in effect until I notify the Company in writing, electronically, by
contacting my agent (if applicable) or by calling a customer service representative at least three (3) days before
my payment due date or effective date of my policy, whichever is sooner.

41846 (10012024)
 Thank you for insuring with us! Here are your identification cards for proof of insurance.

NORTH CAROLINA AUTOMOBILE INSURANCE CARD KEEP THIS CARD IN YOUR MOTOR VEHICLE
Integon General Insurance Corporation NAIC NUMBER Report all accidents immediately to:
PO Box 3199 Winston Salem NC 27102-3199 22780 National General Insurance
INSURED POLICY NUMBER Toll free at: 1-800-468-3466
David Houser 2029846677
Cristy L Houser
Julia Payson Houser EFFECTIVE DATE
Carson Kensley Houser 07/08/2025
189 Cedar Grove Church Rd EXPIRATION DATE
Vale, NC 28168 07/08/2026

YEAR MAKE MODEL VEHICLE IDENTIFICATION NUMBER

1997 TOYT CAMRY CE 4T1BF22K3VU913459

AGENCY: 9034004
Guided Insurance Solutions (877) 611-3030
4211 W Boy Scout Blvd Ste 165
Tampa FL 33607
MOD: 00 10043NC (03012010)

▲
Cut On Solid Line – Fold On Dotted Line
▼

NORTH CAROLINA AUTOMOBILE INSURANCE CARD KEEP THIS CARD IN YOUR MOTOR VEHICLE
Integon General Insurance Corporation NAIC NUMBER Report all accidents immediately to:
PO Box 3199 Winston Salem NC 27102-3199 22780 National General Insurance
INSURED POLICY NUMBER Toll free at: 1-800-468-3466
David Houser 2029846677
Cristy L Houser
Julia Payson Houser EFFECTIVE DATE
Carson Kensley Houser 07/08/2025
189 Cedar Grove Church Rd EXPIRATION DATE
Vale, NC 28168 07/08/2026

YEAR MAKE MODEL VEHICLE IDENTIFICATION NUMBER

2020 DODG DURANGO 1C4RDJAG7LC249282

AGENCY: 9034004
Guided Insurance Solutions (877) 611-3030
4211 W Boy Scout Blvd Ste 165
Tampa FL 33607
MOD: 00 10043NC (03012010)

These are your Temporary Information Cards.

Your Permanent Information Cards will arrive soon in the mail with your Policy.
 OPTIONAL
NATION SAFE DRIVERS ROADSIDE ASSISTANCE PROGRAM
Summary of Benefits and Acknowledgements

Plan Types & Annual Cost:

Plan I: $138.00 Add: $94.00 for each additional vehicle
Semi-Annual Cost:
0000006027629200010602706870005209002030019000010001

Plan I: $78.00 Add: $65.00 for each additional vehicle

ROADSIDE BENEFITS INCLUDE:

24 Hour Emergency Towing Vehicle tow to nearest qualified facility or a facility of your choice within 15 miles
Assistance of vehicle location
Tire Service Dispatch of a service provider to assist in changing an inflated spare tire from
mount to wheel
Lost Keys and Lockout Dispatch of a service provider to assist in gaining entry to your vehicle
Essential Fluids Delivery Deliver of essential fluids for vehicle (gas, water, antifreeze) to the vehicle’s
location (cost of the fluid will be the responsibility of the customer)
Battery Service Jump start or boost a dead battery

THE DIRECT ROADSIDE ASSISTANCE PROGRAM IS NOT AN INSURANCE CONTRACT.

Read The Membership Service Contract For A Full Explanation Of Benefits, Terms & Conditions.
I, the undersigned, hereby acknowledge that my agent has fully explained to me and I understand:
1. The Nation Safe Drivers Roadside Assistance Program is not insurance and does not provide liability coverage
insurance for bodily injury or property damage. It does not meet any financial responsibility law and is not required
by the State.
2. The Nation Safe Drivers Roadside Assistance Program is an optional product that is separate from my
automobile insurance policy. I have a 30 day free look period during which I can cancel with no
obligation. Buying it is not a condition of buying my automobile insurance policy.
3. I am making an informed decision about the optional Nation Safe Drivers Roadside Assistance Program.
4. I have received a signed copy of this summary and acknowledgment.
I HAVE ELECTED TO PURCHASE THE NATION SAFE DRIVERS ROADSIDE ASSISTANCE PROGRAM FOR THE
COST INDICATED ABOVE:

David Houser 2029846678

Applicant’s Name Policy Number:

<PrimarySign> <PrimaryDate>
07/08/2025
Applicant’s Signature Date

All membership benefits are subject to terms and conditions.

TO FILE A CLAIM: For Roadside Assistance call 877-756-6637. Roadside Assistance benefits are provided through Nation Safe
Drivers, 5600 Broken Sound Blvd NW, Boca Raton, FL 33431. (Please also refer to your Service Agreement)

RA-ACK (Rev. 01/18) 12079 (01012018)

 NATION SAFE DRIVERS ROADSIDE ASSISTANCE PROGRAM
Home office: Nation Motor Club, LLC • 5600 Broken Sound Blvd NW, Boca Raton, FL 33431

MEMBER INFORMATION VEHICLE INFORMATION

Name Year Make Model
David Houser 1 2020 DODG DURANGO
0000006027610400010602706870005019002030019000010003

Address 2 1997 TOYT CAMRY CE

189 Cedar Grove Church Rd
City State Zip
Vale NC 28168

SELLER INFORMATION
Name
Guided Insurance Solutions
Address
MEMBERSHIP INFORMATION
4211 W Boy Scout Blvd Ste 165
City State Zip Effective Date Expiration Date Membership Fee
Tampa FL 33607 07/08/2025 07/08/2026 $232.00

For Emergency Roadside Assistance Only Call 877-756-6637

Member #: 2029846678
Producer Code: 26224
Plan Letter: B
For Customer Service Only Call 888-684-9327, Monday through Friday, from 8:30 am - 5 pm eastern time

THIS IS NOT AN INSURANCE CONTRACT

This is not an Automobile Physical Damage or
Automobile Liability insurance contract.
Your Membership contains Our 24 hour emergency road service telephone number for You to call when Your Covered Vehicle is disabled. When
arranging for Roadside Assistance, please call 877-756-6637 and reference Your Producer Code, Member Number and Plan Letter (located above).
You will not be required to pay any additional fee or sum in addition to the Membership Fee when Your service is for a tow up to fifteen (15) miles or
other covered service listed below. You are entitled to one (1) covered service within a seventy two (72) hour period. Covered services not obtained
through Us are limited to a maximum reimbursement amount of fifty dollars ($50).
Towing: Up to fifteen (15) miles at no out of pocket expense to You. Additional mileage is available and will be negotiated prior to sending out a service
vehicle. Additional mileage is to be paid by You directly to the service provider at the time of service.
Mechanical First Aid: Any minor adjustment that a dispatched service provider might perform to allow Your Covered Vehicle to proceed safely under
its own power.
Tire Service: Includes changing a flat tire with Your good spare.
Battery Service: Jumpstart or boost a dead battery.
Delivery Service: Including gasoline, water, oil, or any supplies necessary to send Your Covered Vehicle on its way. You are responsible for the
actual cost of fluid and/or supplies delivered.
Lockout Services: We will send a locksmith if You are accidentally locked out of Your Covered Vehicle. Access to passenger compartment only.
Limit: No more than five (5) service calls within twelve (12) months.
ADDITIONAL BENEFITS
Theft Hit & Run Protection: We will pay a person, (excluding Member or Member's family) five hundred dollars ($500) for information leading to the
arrest and conviction of a person for the theft of a Your Covered Vehicle or tagged valuable articles.
Rental Car Discounts: You may access car rental discounts for: NATIONAL (1-877-222-9058 ID# XZ41148 PIN# NSD); THRIFTY (1-800-367-2277
ID# 0010027892); and ENTERPRISE (1-800-736-8222 ID# XZ41148 PIN# NSD)
Concierge Benefits: You may contact Our Concierge center at 1-855-963-1683, and give the producer code number listed on the front of this
Membership, twenty four (24) hours a day / seven (7) days a week, to speak with a representative who will assist You with the following concierge
services: a) emergency message relays to family friends or co-workers; b) hotel and rental car availability; c) ATM locations; d) locate medical facilities;
e) theme park and local attraction information; f) restaurant locations; g) movie schedules and locations; h) directional assistance; i) traffic alerts; and j)
sport scores. Please note: Services provided are for informational purposes ONLY. You are responsible for making any/all payment arrangements and
for setting up benefits that require additional billing, such as the actual cost of hotel rooms, rental cars, etc. Payment is to be made directly by You to the
providers, vendors or establishments.

TBnR 10/14 131

 TERMS AND CONDITIONS
You, Your, Member means the individual(s) listed in the registration section of this Membership;
We, Us or Our means the Provider/Administrator of the Motor Club benefits and services;
Covered Vehicle means the vehicle(s) listed in the registration section of this Membership;
All benefits are available to You up to Your benefit limit, as described throughout this Membership, without any additional payments. You are
responsible for any non-covered expenses;
Your Membership begins on the Effective Date as shown above and continues until the Expiration Date, unless cancelled.
0000006027610500010602706870005019002030019000020003

All of the benefits and services of Your Motor Club Membership are described herein and are applicable throughout the United States, Canada and
Puerto Rico;
All services and benefits are Administered through Nation Safe Drivers, LLC. dba Nation Safe Drivers located at 5600 Broken Sound Blvd NW, Boca
Raton, FL 33431. In California: All services and benefits are Administered through Nation Motor Club, LLC. located at 5600 Broken Sound Blvd NW,
Boca Raton, FL 33431. California Motor Club Permit Number: 5157-3. In Alabama, Alaska, Utah & Virginia: All services and benefits are Administered
through Nation Safe Drivers Services, Inc.;
For Customer Service please contact the Administrator at 888-684-9327, Monday through Friday, from 8:30 am - 5 pm eastern time;
All claims must be reported to the Administrator at 5600 Broken Sound Blvd NW, Boca Raton, FL 33431; 888-684-9327;
You have the right to file a complaint by submitting a written complaint to Our Customer Service Department at 5600 Broken Sound Blvd NW, Boca
Raton, FL 33431 or by calling 888-684-9327, Monday through Friday, from 8:30 am - 5 pm eastern time;
You may obtain a full copy of Our company's privacy notice by sending a written request to the Administrator, Attention: Privacy Notice Department,
5600 Broken Sound Blvd NW, Boca Raton, FL 33431.
EXCLUSIONS
This Membership does not cover the following: a) Any violation of motor vehicle or traffic laws relating to the operation of a motor vehicle; b) Driving
under the influence of intoxicating liquors, narcotics or psychedelic drugs; c) Driving without a valid operator's permit, or leaving the scene of an accident
without disclosing identity, or failing to stop to ascertain injury and lend assistance (i.e. hit and run); d) When any motor vehicle is operated without
permission of the owner thereof; e) Service for trucks in excess of one ton chassis, busses, trailers, tractors, or vehicles of dual wheel class; f) Any
service requiring removal of snow or ice from or around Your Covered Vehicle(s), or from any driveway or premises, or street, highway or parking area;
g) Gas/credit card receipts are not accepted; h) Reimbursement sought for any bill which, in Our opinion appears to be false or fraudulent, and not for
the claimed services; i) Any parts of the Covered Vehicle, rental battery or return of rental battery. Supplies or accessories furnished by garage or
service station shall be at the sole expenses of the Member; j) All repairs and material used in repairing flat tire, or services requiring more than one trip
by garage or service station shall be at the sole expense of the Member; k) By being involved in any traffic accident or any accident involving a motor
vehicle in which a Police Traffic Accident Report is not filed or made a matter of record; l) In which You or any person intentionally causes damage to the
Covered Vehicle; drives in any competition, race or speed contest or in preparation for same; or causes any accident while committing or attempting to
commit a felony or other illegal act including but not limited to fleeing from police; m) Due to war or any warlike act, whether war is declared or not,
terrorism, acts of God or vandalism.
CANCELLATION
If this Membership is cancelled by You within thirty (30) days from the Effective Date, You will receive a refund of the full purchase price, less the
amount of any claims paid or payable. If You cancel this Membership after the first thirty (30) days, You will be refunded by the Administrator on a
prorated basis, less a cancellation fee of fifty dollars ($50) and the amount of any claims paid or payable. All cancellation requests must be submitted in
writing to the Administrator and signed by You.
TRANSFER
This Membership cannot be transferred.
STATE PROVISIONS
The following state specific requirements apply if Your Membership was purchased in one of the following states:
LOUISIANA
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis, less a cancellation fee of twenty five dollars ($25). All cancellation requests must be submitted in writing to the
Administrator and signed by You.
MARYLAND
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis. All cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 351 West Camden Street, Baltimore, MD 21201; (410) 225-2995
MASSACHUSETTS
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis, less a cancellation fee of twenty five dollars ($25). All cancellation requests must be submitted in writing to the
Administrator and signed by You.
MISSISSIPPI
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis, less a cancellation fee of twenty five dollars ($25). All cancellation requests must be submitted in writing to the
Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 645 Lakeland East Drive, Suite 101, Flowood, MS 39232

TBnR 10/14
 MONTANA
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis. All cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 208 North Broadway, Suite 313, Billings, MT 59404
NEVADA
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis. All cancellation requests must be submitted in writing to the Administrator and signed by You.
0000006027610600010602706870005019002030019000030003

Other Offices: Nation Motor Club, LLC. dba Nation Safe Drivers, 311 South Division Street, Carson City, NV 89703
NEW MEXICO
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis. All cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 123 East Marcy, Santa Fe, NM 87501
OKLAHOMA
The Cancellation section of this Membership is replaced in its entirety by the following: This Membership can be cancelled by You or the Administrator at
any time. You will be entitled to the unused portion of the amount paid for the Membership calculated on a prorated basis over the period of the contract,
without any deductions. The refund will be payable to You or the Lienholder, where applicable. All cancellation requests must be submitted in writing to
the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 1833 South Morgan Road, Oklahoma City, OK 73128
TENNESSEE
The Theft Hit & Run Protection benefit in this Membership is not applicable.
WISCONSIN
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis, less a cancellation fee of twenty five dollars ($25). All cancellation requests must be submitted in writing to the
Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 8040 Excelsior Drive, Suite 200, Madison, WI 53717
WYOMING
The Cancellation section of this Membership is replaced in its entirety by the following: If this Membership is cancelled by You within thirty (30) days
from the Effective Date, You will receive a refund of the full purchase price. If You cancel this Membership after the first thirty (30) days, You will be
refunded on a prorated basis. All cancellation requests must be submitted in writing to the Administrator and signed by You.
Other Offices: Nation Motor Club, LLC., 1712 Pioneer Avenue, Suite 200, Cheyenne, WY 82001

Lauren Smith, Secretary 10/14

By Your signature below, You acknowledge and agree that Your acceptance of this Membership is voluntary. It is understood by the
undersigned that coverage afforded under this Membership applies only to the Covered Vehicle listed in the registration section of this
Membership. This Membership does not comply with the financial responsibility or no-fault laws of any state or territory.

<PrimarySign> <PrimaryDate>
07/08/2025
Member’s Signature Date

<ESigAgent> <ESigAgentDate>
Signature of Seller Date

TBnR 10/14