12535 Totem Lake Blvd NE

Payment Receipt Kirkland WA 98034

New Business Phone : 425-821-6084
Transaction #51521142 License # 1070622
New Business #37600706 Office : 953 Kirkland-Totem Lake

Gheorghe Miclescu Customer #24638012

2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

Fees
Added Date Type Description Amount
7/8/2025 Automobile Insurance Down Payment to Carrier $150.47
7/8/2025 Agency Fee Agency Fee $60.00
7/8/2025 SR-22 Fee Agency Fee $50.00

Total Fees: $260.47

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Received Payments

Received Date Type Description Credit Card # / Check # / Other Amount

7/8/2025 Credit Card Card# *5276 $260.47
Total Amount Received : $260.47

TOTAL PAYMENT : $260.47

By way of this receipt, I acknowledge that I have may conducted this insurance transaction with an affiliated company. Any
sharing of my information by and amongst these affiliates is solely for the purpose of completing the insurance transaction.
Affiliated companies are listed here: https://www.freeway.com/affiliate-disclosure/

Customer Service: (800) 300-0227

Policy Number: 11410386740 Insurance Company: Dairyland Auto Insurance

Customer Signature: Agent Signature:

BIG SAVINGS!
Find out more about our additional products:
• Auto • Motorcycle • Renter’s • Roadside Assistance
• Identity Theft • AD&D • Telemedicine
• Windshield Repair

Ask your agent or call: 888-263-1473

Page 1
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

LIVERY (UBER – LYFT – RIDE SERVICE)

AND FOR-HIRE (DELIVERY/Pick-Up) DISCLOSURE

Policy #: 11410386740

I, Gheorghe Miclescu hereby acknowledge that neither myself nor anyone who is intended to be a covered driver (or permissive
user) under this policy uses the vehicle(s) disclosed on the application (or any other vehicle added at a later date) for any:

a) For-Hire ride or driving service, including but not limited to UBER, RIDE, LYFT, TAXI, LIMOUSINE, or similar Shuttle or

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Ride-For-Hire or Ride Share service.
b) Delivering or picking up property, goods, or products, INCLUDING BUT NOT LIMITED TO pizza, documents, newspapers,
food, flowers, equipment, supplies, or consumer products;

Failure to accurately attest to the foregoing may lead to your policy being cancelled or coverage/claims being denied.
Customer must also inform the insurance carrier or Freeway immediately upon engaging in the above services.

Signed and acknowledged this 7/8/2025

Customer Signature

Page 2
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

Date: 7/8/2025

Household Member Disclosure

A driver should be listed on your automobile policy if they:

1. Live in the same household, have an active drivers license, and do not have an automobile policy of
their own.
2. Use a vehicle on your policy on a regular or occasional basis regardless of whether they live in the
same household or not.

I, Gheorghe Miclescu , do hereby represent that I have listed all drivers/operators of the insured motor
vehicle(s) on the Carrier Application, and all residents of my household (over the age of 14 and regardless

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

of whether they drive the vehicle) on the Carrier Application or Named Driver Exclusion document.

I agree to notify my insurance company of any new drivers and/or residents of my household (including
those who have since turned the age of 14) should changes occur during the term.

Address Verification Disclosure

The garaging location is commonly referred to as the location where the vehicle sleeps at night. If the vehicle
stays at more than one location during the year, the garaging location can be determined by how long the
vehicle stays at each location. Wherever the vehicle stays for the majority of the year, should be the
garaging location.
I certify that the mailing and garaging addresses indicated on this application are true and accurate.

Furthermore, I agree to notify the Company of any changes of: (1) Resident Address, (2) Garaging Address
of Vehicles insured.

NOTICE: FAILURE TO ACCURATELY DISCLOSE AND UPDATE GARAGING ADDRESS, DRIVERS AND
HOUSEHOLD MEMBERS MAY LEAD TO RESCISSION OF YOUR POLICY AND DENIAL OF ANY CLAIMS.

Applicant’s Signature:

Print Applicant’s Name: Gheorghe Miclescu

Page 3
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

Freeway Insurance Services America, LLC (Washington)

Replacement Policy Disclosure

By signing below, I acknowledge that I have read all the terms, coverages, effective date and pricing
for the insurance policy I am purchasing.

If the effective date of this policy, which can be found on the policy contract, is in the future,

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

I acknowledge that I have no coverage until that date.

If I am buying a replacement policy for a policy that is active or re-instatable, or because I am making
changes (endorsements) to the policy, I acknowledge that I have reviewed the coverage(s), pricing and
fees with my producer. If the pricing is higher, I have voluntarily selected a new carrier after discussing
options with the producer.

Insured Signature

Page 4
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

Consent to Receive Text Messages

Customer Name: Gheorghe Miclescu

Phone Number(s): (910) 224-3595

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

I agree to the Freeway Insurance Services America, LLC (Washington) Privacy Policy and Terms of Use , and I
give consent to share my information with Freeway Insurance Services America, LLC
(Washington)’s Affiliates, External Marketing Partners, and their successors and assigns. For all of these, I
also give my express written consent to be contacted at the mobile phone number provided above for marketing
purposes by call, text, or automated telephone dialing system, including with an artificial or prerecorded voice,
which may leave a message. Message and data rate may apply. Message frequency varies. Text HELP for help and
STOP to cancel at any time. I understand that I am providing this consent even if my telephone number is currently
listed on a federal, state, internal, or corporate Do-Not-Call list. I understand that I do not have to agree to receive
these types of calls or text messages as a condition of purchasing any goods or services.

Signature

Page 5
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

Confie U.S. Consumer Privacy Notice

WHAT DOES CONFIE HOLDING II CO.

(“CONFIE”) DO WITH YOUR PERSONAL
INFORMATION?
Why? Financial companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you how
we collect, share, and protect your personal information. Please read this notice carefully to
understand what we do.

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

What? The types of personal information we collect and share depend on the product or service you
have with us. This information can include:
• Social Security number and Income

• Payment History and Transaction History

• Credit History and Insurance Claim History

How? All financial companies need to share customers’ personal information to run their everyday
business. In the section below, we list the reasons financial companies can share their customers’
personal information; the reasons Confie chooses to share; and whether you can limit this
sharing.

Reasons we can share your personal information Does Confie share? Can you limit this sharing?

For our everyday business purposes—

such as to process your transactions, maintain
Yes No
your account(s), respond to court orders and
legal investigations, or report to credit bureaus

For our marketing purposes—

Yes No
to offer our products and services to you

For joint marketing with other financial companies Yes No

For our affiliates’ everyday business purposes—

Yes No
information about your transactions and experiences

For our affiliates’ everyday business purposes—

Yes Yes
information about your creditworthiness

For our affiliates to market to you Yes Yes

For non-affiliates to market to you Yes Yes

Page 6
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

To limit ▪ Call 877-214-0149 – our menu will prompt you through your choice(s)
our sharing ▪ Visit us online: https://www.freeway.com/privacy-policy/
▪ Mail the form below
Please note:
If you are a new customer, we can begin sharing your information 30 days from the date we sent
this notice. When you are no longer our customer, we continue to share your information as
described in this notice.
However, you can contact us at any time to limit our sharing.

Questions? Call 877-214-0149 or go to https://www.freeway.com/privacy-policy/

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Page 7
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT


Mail-in Form
If you have a joint Mark any/all you want to limit:
policy, your
choice(s) will apply Do not share information about my creditworthiness with your affiliates for their everyday
to everyone on your business purposes.
account unless you
Do not allow your affiliates to use my personal information to market to me.
mark below.
[_] Apply my Do not share my personal information with nonaffiliates to market their products and
choice(s) only services to me.
to me.
Name Mail to:
Address Freeway Insurance Services

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

ATTN: Customer Service
Escalations Team
City, State, Zip 4630 Border Village Rd.,
Policy # STE 2018
San Ysidro, CA 92173

Who we are

Who is providing this notice? The companies listed at https://www.freeway.com/affiliate-disclosure/

What we do
How does Confie protect my personal To protect your personal information from unauthorized access
information? and use, we use security measures that comply with federal law.
These measures include computer safeguards and secured files
and buildings.
Access to information in our possession is limited to those employees
who need it to perform services, process transactions, or marketing.
How does Confie collect my personal We collect your personal information, for example, when you
information?
• Make an inquiry about an insurance product or service

• Apply for insurance or pay insurance premiums

• File an insurance claim or provide account information

We also collect your personal information from others, such as credit
bureaus, affiliates, or other companies.
Why can’t I limit all sharing? Federal law gives you the right to limit only

• sharing for affiliates’ everyday business purposes—

information about your creditworthiness

• affiliates from using your information to market to you

• sharing for non-affiliates to market to you

State laws and individual companies may give you additional rights to
limit sharing. See below for more on your rights under state law.

Page 8
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

What happens when I limit sharing Your choices will apply to everyone on your account – unless you tell us
for an account I hold jointly with otherwise.
someone else?

Definitions
Affiliates Companies related by common ownership or control. They can be
financial and nonfinancial companies.
• Our affiliates are listed at https://www.freeway.com/affiliate-
disclosure/
Non-affiliates Companies not related by common ownership or control. They can be
financial and nonfinancial companies.
•

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Nonaffiliates we share with can include companies such as
insurance companies, insurance agencies, mortgage brokers,
bankers, securities broker-dealers, airlines, direct marketing
companies, and others.
Joint marketing A formal agreement between nonaffiliated financial companies that
together market financial products or services to you.
• Our joint marketing partners may include insurance companies,
insurance agencies, and others.
Other important information
You may have other privacy protections under applicable state laws. To the extent these state laws apply, we will
comply with them when we share information about you.

CALIFORNIA RESIDENTS. Important Privacy Choices for California Residents. If you are a resident of California, we
will not disclose your financial information with any non-affiliated companies for marketing unless the disclosure is
otherwise permitted by law or you give us your express prior consent. We may also disclose your financial information
for marketing purposes to affiliated companies, and to non-affiliated companies with which we have contracts to provide
financial products or services to you, but not until we provide you with an opportunity to opt-out of such disclosure and
you do not opt-out. To exercise your California opt-in and opt-out rights related to our disclosure of your financial
information for marketing purposes, please visit https://privacychoices.confie.com/.

MONTANA RESIDENTS. If you are a resident of Montana, we will not disclose your financial information to non-affiliated
companies for their marketing purposes unless the company has an insurance license, you authorize us to do so, or as
permitted by law.

RESIDENTS OF NEW MEXICO, NORTH DAKOTA, AND VERMONT. If you are a resident of New Mexico, North
Dakota, or Vermont, we will not disclose your financial information to non-affiliated companies unless you expressly
authorize us to do so. This does not prohibit us from disclosing your Financial Information to third parties that perform
business services for us or that assist us in servicing your policy or fulfilling a request made by you, or as otherwise
permitted by law.

Personal Insurance Waiver

You should refer to your policy documents provided by the carrier for specific coverage
descriptions concerning your policy.

Page 9
Gheorghe Miclescu Customer #24638012
2226 Eastlake Ave E Pmb 236 Received By: Timothy Methven
Seattle WA 98102-3419 Print Date/Time : 7/8/2025 10:35 AM PDT

I have reviewed the following (initial each section):

________ I understand that I have purchased the policy based on my current

occupancy, for example: owner occupied, rental property, vacant, etc.

________ If the occupancy or the usage of my home changes, I agree to contact my

agent to add the appropriate endorsements or rewrite the policy to the
proper contract form.

________ Higher limits of liability coverage are available for an additional cost. At this
time, I have declined to purchase the higher limits.

Date:7/8/2025

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Insured Signature:

Page 10
 Universal Deal Checklist (AppOne)
Binding/Carrier Paperwork
 All carrier guidelines met.
 All required documents uploaded (driver’s license, registrations, proof of prior insurance, marriage, ITC, etc.).
 Where does the application need to be signed and/or initialed?
 File scanned within 2 hours.
 All paperwork scanned correctly. (If not, open a ticket and follow up with IT.)
 Carrier application properly bound with a policy number.
 Correct effective date on the application.
 Submitted amount—premium and applicable fees—uploaded correctly.
 Address, driver’s license, coverages, and vehicle(s) match in the carrier application, AppOne, and the Insurance
101-GCD Form.
 EFT agreement completed correctly. (Signature needed from bank account holder, not always same as policy
holder.)
 Added New Business Correction Form and proof of confirmation (if applicable).

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

 Uploaded or scanned ITC quote sheet (if required by state).
 Customer signature on any carrier endorsement for ride sharing (if applicable).
 Customer signature and proof of fax to carrier on any needed carrier driver exclusion documents (to prevent
cancellation).
 Uploaded exclusion form confirmation in operating system.
 Copies of the insured’s driver’s license and registration.
 Noted in system whether our customer is an in-store or phone sale.
FWY Paperwork
 All required FWY Forms are scanned and signed correctly. Includes:
 Privacy Notice, Household Member Disclosure, and Livery Ride Sharing Disclosure
 All other applicable forms (My Plan Coverage Checklist, Fee Disclosure Statement, Customer Receipt, SR-22
Disclosure Notice, Cancellation Request for policies being rewritten, Vehicle Inspection Form for Comp and
Collision, Quote Sheet, Driver Exclusion)
 Store customers only: All information on the Customer Profile correct, matching client information.
 Use scan cover sheet to confirm required documentation.
 ESign customers only: Check EchoSign document history confirmation.
CK/CC Barcode
 Funds collected at point of sale to cover submission amount (payment method and amount bridged correctly to
AppOne).
 Customer signature on Deferred Down Payment Agreement (hold credit card or promissory note, if applicable)
Photos
 Photos uploaded to AppOne (if required by carrier)
 Photos do not show existing damage, special equipment, or any other modifications.
 Uploaded signed Vehicle Inspection.
Proof of Ownership (VR)
 Uploaded proof of ownership (if required).
 Registered owners are excluded or rated per carrier guidelines (Vehicle, VIN, make, year, and model).
Additional Products
 Added NSD contract signed by the customer and seller.
 Customer info and amount collected match with payment receipt.
 NSD Membership number matches in operating system.

Producer Signature ____________________________________ Manager Signature _______________________________

Revision: 3/11/2021
 Your Insurer is Patriot General Insurance Company
Agency: FREEWAY INSURANCE SERVICES AMERICA LLC
Phone: 1-425-821-6084

My.DairylandInsurance.com

FREEWAY INSURANCE SERVICES AMERICA LLC

7711 CENTER AVE STE 200
HUNTINGTON BEACH CA 92647 DECLARATIONS PAGE
Policy Number 11410386740
Named Insured(s)
Policy Term 07/08/2025 to 01/08/2026
Transaction 07/08/2025 12:39 PM Central
MICLESCU, GHEORGHE Effective Time, per Stevens Point WI
2226 EASTLAKE AVE E PMB 236

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Transaction New Business
SEATTLE WA 98102 Type
DFDDFTTADFFTFDFFDFAAATTAADFADTAFTTFTADADTTDATAFFDADFDFAATFTAFTTAT

Email: NONUNE829@GMAIL.COM

This Is Not a Bill. Retain for your records.

Premium and Coverage Information
A Named Non-Owner Policy provides the selected coverage for the Named Insured while driving non-owned cars.
Coverage does not apply when driving a non-owned car available for regular use by the Named Insured.
Policy Level Coverages Limits Deductible Premium
Bodily Injury Liability $25,000 Each Person/$50,000 Each accident $489.60
Property Damage Liability $10,000 Each accident $365.58
Underinsured Motorist Bodily Injury Rejected
Personal Injury Protection Rejected
Subtotal Premium By Policy $855.18

Premium Summary
Term Premium Total (excludes fees) $855.18
Policy Fee $8.00

Fee Information
The following fees may be charged during the life of the policy.
Automatic Reinstatement Rewrite Fee Billing Fee Policy Fee Late Fee Returned
Payments Billing Fee Payment Fee
Fee
$3.00 $20.00 $8.00 $8.00 $8.00 $5.00 $25.00

Vehicle Information
Residential Zip: 98102 Named Non-Owner Policy

Driver Information
Marital
Drv # Name Date of Birth Gender Financial Responsibility
Status
1 MICLESCU, GHEORGHE XX/XX/1989 M S SR22 WA

Accident and Violation Information

Drv # Date of Occurrence Type Points Description of Occurrence
1 07/19/2024 Violation 5 Operating on Expired License

DECA-1122 Process Date: 07/08/2025 - 12:39 PM Central Time per Stevens Point, WI Page 1 of 2
Policy Forms
The following policy forms and endorsements apply to your policy.
DRE1-WA-0915 MPHN1-0121 NNO1-WA-0915
PAP1-1213 PPA-WA-1217 WAA1101-0223
WAPIP-1217 WAUIM-0517

Important Messages
This policy is effective on the date and time shown on the face of these declarations. These declarations form a part of
the policy.
Access your policy documents online at My.DairylandInsurance.com.

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

DECA-1122 Process Date: 07/08/2025 - 12:39 PM Central Time per Stevens Point, WI Page 2 of 2
WASHINGTON Policy Number 11410386740
AUTO APPLICATION Effective Date: 07/08/2025
12:39 PM Central Time per Stevens Point, WI
Patriot General Insurance Company
My.DairylandInsurance.com
Named Insured(s) Agency
MICLESCU, GHEORGHE Freeway Insurance Services America LLC
2226 Eastlake Ave E PMB 236 Nicolai Quezada
Seattle WA 98102 7711 Center Ave Ste 200
Phone: 910-224-3595 Huntington Beach CA 92647
Email: NONUNE829@GMAIL.COM Phone: 425-821-6084

Premium and Coverage Information Type Named Non-Owner Policy Term 6 Month
A Named Non-Owner Policy provides the selected coverage for the Named Insured while driving non-owned cars.
Coverage does not apply when driving a non-owned car available for regular use by the Named Insured.
Policy Level Coverages Limits Deductible Premium
Bodily Injury Liability $25,000 Each Person/$50,000 Each accident $489.60
Property Damage Liability $10,000 Each accident $365.58

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Underinsured Motorist Bodily Injury Rejected
Medical Payments Not Selected
Accidental Death Not Selected
Personal Injury Protection Rejected
Subtotal Premium By Policy $855.18

Premium Summary
Term Premium Total (excludes fees) $855.18
Policy Fee $8.00
Total Cost $863.18
Total Amount Submitted $150.47
Pay Plan 5 Installments
Automatic Payments Y

Fee Information
The following fees may be charged during the life of the policy. These fees may change.
Automatic Reinstatement Rewrite Fee Billing Fee Policy Fee Late Fee Returned
Payments Billing Fee Payment Fee
Fee
$3.00 $20.00 $8.00 $8.00 $8.00 $5.00 $25.00

Discount Information: None

Surcharge Information: None

Vehicle Information
Residential Zip: 98102 Named Non-Owner Policy

Driver Information
Marital License
Drv # Name Date of Birth Gender License Number Financial Responsibility
Status State
1 MICLESCU, GHEORGHE 01/09/1989 M S WA *** SR22 WA

Accident and Violation Information

Drv # Date of Occurrence Type Points Description of Occurrence
1 07/19/2024 Violation 5 Operating on Expired License

Named Insured Confirmation

I understand and agree this application is a part of the policy.

WAA1101-0223 (Policy # 11410386740) Page 1 of 2

I understand and agree this policy does not take effect until the effective date and time listed on this application.
I understand and agree if a payment made by me or on my behalf is not honored by the financial institution, it will not be
considered a valid payment and coverage may not be afforded under this application and subsequent policy.
I understand and agree any unpaid balance owed, including any fees, at the time of cancellation, non-renewal or
expiration is a debt the Company may attempt to collect, and in addition to this unpaid balance, I must pay for any costs
and attorney fees the Company may incur to collect this amount.
I understand and agree the Company may obtain facts from third parties such as consumer reporting agencies or policy
verification services that provide driving and claims histories on all drivers rated on this policy. I understand and agree
new or updated consumer information may be used to calculate my renewal premium. I may access this information
directly from the third party and correct it if it is inaccurate.
I understand and agree this policy may be cancelled, rescinded, and/or coverage denied if this application contains any
false statement, omission, or material misrepresentation that was made with the intent to deceive and would have
otherwise altered the Company’s evaluation of the policy.
I understand and agree I must report to the Company all persons of legal driving age or older who live with me temporarily
or permanently, including all children at college. I understand I must report all persons who are regular operators of any
vehicle to be insured, regardless of where they reside.
I understand and agree none of the vehicles will be used to carry persons or property for compensation or a fee, or for

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

retail or wholesale delivery, including, but not limited to, the pickup, transport or delivery of magazines, newspapers, mail
or food.
I have had Special Equipment Coverage explained to me and fully understand it. I understand and agree when collision
and/or comprehensive coverages are purchased, no coverage will exist for equipment that has not been installed by the
original manufacturer of the vehicle unless Special Equipment Coverage has been purchased.
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
DRIVER RESTRICTION - READ CAREFULLY: I understand and agree the insurance policy I am requesting will not apply
for Liability and Car Damage coverages while the insured vehicle is being driven by any person under the age of
twenty-five unless that person is listed as a driver on this application and on the policy at the time of loss.
As a member of Sentry Mutual Holding Company ("Sentry MHC"), I hereby appoint the President and/or Secretary of
Sentry MHC, and each of them, to vote my proxy at any and all meetings of members at which I am not present in person
or by subsequent proxy. This proxy shall remain in force during the term of this policy and any renewal or replacement
policy, or until expressly revoked or superseded.
I understand and agree it is my responsibility to report any change of residential location to the Company within 14 days
of the change.

I hereby apply to the company for a policy of insurance. The above facts are true and complete. I understand this policy is
to be issued in reliance upon these facts being true.
AM
07/08/2025 PM *
Date Signed Time Signed Named Insured's Signature
I certify I have entered the information provided to me by the applicant(s) and I have read to them all of the confirmation
statements on the application.
AM
07/08/2025 PM *
Date Signed Time Signed Producer's Signature

(Policy # 11410386740)
WAA1101-0223 Page 2 of 2
Patriot General Insurance Company

My.DairylandInsurance.com

WASHINGTON PERSONAL INJURY PROTECTION (PIP) COVERAGE REJECTION

X I reject Personal Injury Protection (PIP) Coverage in its entirety.

I fully understand PIP Coverage. I understand the rejection I have made will apply to all vehicles insured under this policy
and all insureds. I also understand this rejection applies to this policy and extension, renewal, change or reinstatement of
it by the Named Insured unless the Named Insured subsequently requests a change. It also applies to any reissuance of
the policy by the Company.

07/08/2025

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Named Insured's Signature Date

WAPIP-1217 (Pol # 11410386740) Page 1 of 1

Patriot General Insurance Company

My.DairylandInsurance.com

WASHINGTON UNDERINSURED MOTORISTS COVERAGE REJECTION

Underinsured Motorist Coverage means coverage for underinsured motor vehicles. An underinsured motor vehicle is
defined as a motor vehicle with respect to the ownership, maintenance, or use of which either no bodily injury or
property damage liability bond or insurance policy applies at the time of an accident, or with respect to which the sum of
the limits of liability under all bodily injury or property damage liability bonds and insurance policies applicable to a
covered person after an accident is less than the applicable damages which the covered person is legally entitled to
recover.

X I reject Underinsured Motorists Bodily Injury (UIM-BI) Coverage in its entirety.

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

I reject Underinsured Motorists Property Damage (UIM-PD) Coverage in its entirety.
In order to provide for an informed decision of the potential consequences of rejecting underinsured motorist
coverage; the undersigned acknowledges that by rejecting underinsured motorist coverage there is exposure to
the risk of not being sufficiently insured for injury and/or damages when involved in an accident with a driver of
an underinsured vehicle.

I fully understand UIM-BI and UIM-PD Coverage. I understand the rejection I have made will apply to all vehicles insured
under this policy and all insureds. I also understand this rejection applies to this policy and extension, renewal,
change or reinstatement of it by the Named Insured unless the Named Insured subsequently requests a change. It also
applies to any reissuance of the policy by the Company.

07/08/2025
Named Insured's Signature Date

WAUIM-0517 (Pol # 11410386740) Page 1 of 1

Patriot General Insurance Company

My.DairylandInsurance.com

NAMED NON-OWNER ACKNOWLEDGEMENT

I understand the only person afforded the benefit of Liability coverage under this Named Non-Owner policy is the Named
Insured as listed on the Declarations Page. I am also aware no coverage is afforded to me under this policy if I am using a
vehicle I own or as described per this policy's Named Non-Owner endorsement.

07/08/2025
Named Insured's Signature Date

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

GN1006-0915 (Pol #11410386740) Page 1 of 1
Patriot General Insurance Company

My.DairylandInsurance.com

AUTOMATIC PAYMENTS AUTHORIZATION AGREEMENT

I hereby authorize the Company to initiate recurring variable payments (debits) on or about the due date of the policy or
the next business day from the payment account identified below for payments due to the Company. I understand and
agree the Company may electronically retain my payment information. Recurring variable payments will continue until the
policy permanently terminates or the automatic payments authorization is cancelled by me or the Company.
If any premium payment is not honored by the financial institution or card issuer, coverage on the policy for which
payment is to be applied may be cancelled or voided for nonpayment of premium, unless alternative payment
arrangements have been made prior to the premium due date. If the payment is not honored for any reason by the
financial institution or card issuer, I am responsible for making the payment and any associated late or returned payment
fees charged by the Company.
If the financial institution or card issuer does not honor the payment on the effective date of the payment, the Company
may (but is not obligated to) attempt additional withdrawals. I agree the financial institution or card issuer will not be liable
for any payment request that is not honored, and I understand and agree I am ultimately responsible for any financial

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

institution or card issuer fees from the initial or subsequent payment attempts.
This authorization applies to the below listed policy and any extension, renewal, change or reinstatement of the policy.
This authorization will remain in effect until I request termination by calling Customer Service at 1-800-334-0090 or by
logging into my policy online at least one (1) business day before the due date.
Named Insured(s): MICLESCU, GHEORGHE Policy Number: 11410386740
Checking/Savings Account Information:
Routing # (9 numbers): Account # (no more than 17 numbers): Account Type:
Checking
Savings
X Debit/Credit Card Account Information:
(Visa, MasterCard, Discover, American Express accepted; non-reloadable prepaid cards are not allowed)
Card # (no more than 16 numbers): Exp. Date: CVV/Secure Code (no more than 4 numbers):
visa5276 07/29 ****

Account Holder Information:

Gheorghe Miclescu
Name
2226 Eastlake Ave E PMB 236
Address
Seattle WA 98102
City State Zip

By providing us with an email address, we will send payment notifications to the accountholders email address.
NONUNE829@GMAIL.COM
Email
By signing below, I acknowledge I am authorized to use this account, and I agree to the above terms. If authorization was
obtained over telephone, I understand and acknowledge I electronically signed this form using voice signature.

07/08/2025
Signature Date

To enroll, make changes, or cancel this authorization: Write Customer Service

Go to My.DairylandInsurance.com PO Box 8034
Call 1-800-334-0090 Stevens Point, WI 54481-8034

GN1508-0820 (Policy Number 11410386740) Page 1 of 1

 FREEWAY INSURANCE SERVICES AMERICA LLC
PATRIOT GENERAL INSURANCE COMPANY
7711 CENTER AVE STE 200
HUNTINGTON BEACH CA 92647 Phone: 1-425-821-6084
Agency Code: 10087989

My.DairylandInsurance.com
Named Insured(s)

Print Date: 07/08/2025

MICLESCU, GHEORGHE Policy Number: 11410386740
2226 EASTLAKE AVE E PMB 236
SEATTLE WA 98102
DFDDFTTADFFTFDFFDFAAATTAADFADTAFTTFTADADTTDATAFFDADFDFAATFTAFTTAT

PAYMENT SCHEDULE
The payment schedule for the term effective 07/08/2025 to 01/08/2026 will be:

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Due Date Withdrawal Date Amount (includes fees)
08/08/2025 08/08/2025 $145.54
09/08/2025 09/08/2025 $145.54
10/08/2025 10/08/2025 $145.54
11/08/2025 11/08/2025 $145.54
12/08/2025 12/08/2025 $145.55

Automatic Payments have been selected. The amount due will be withdrawn from the account on the automated
withdrawal date or the next available business day. Please call 1-800-334-0090 or log in to the policy at
My.DairylandInsurance.com at least one (1) business day before the automated withdrawal date to modify or stop the
Automatic Payment.

Enroll in bill alerts. Receive text or email payment reminders when the due date's near, and never miss a payment again!
You can even pay online directly from the text or email.

Go paperless. View bills and policy documents anytime at My.DairylandInsurance.com.

If you have questions, please contact Customer Service at Help@DairylandInsurance.com or 1-800-334-0090.

We appreciate your business and look forward to serving you in the future.

Nothing contained in this Schedule changes the effective dates listed on any outstanding bill, nonrenewal notice, expiration notice, or cancellation notice
sent.

GN1515-0915 Process Date: 07/08/2025 - 12:39 PM Central Time per Stevens Point, WI Page 1 of 1
FREEWAY INSURANCE SERVICES AMERICA LLC
PATRIOT GENERAL INSURANCE COMPANY
7711 CENTER AVE STE 200
HUNTINGTON BEACH CA 92647 Phone: 1-425-821-6084
Agency Code: 10087989

July 8, 2025
My.DairylandInsurance.com
Named Insured(s)

MICLESCU, GHEORGHE
2226 EASTLAKE AVE E PMB 236
SEATTLE WA 98102
DFDDFTTADFFTFDFFDFAAATTAADFADTAFTTFTADADTTDATAFFDADFDFAATFTAFTTAT

PAYMENT RECEIPT

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Thank you for your payment to Dairyland Auto®.

Please retain for your records.

Auto: 11410386740

Named Insured(s): MICLESCU, GHEORGHE

Amount (US$): $150.47

Method of payment: Cash

Submitted: 07/08/2025 12:39 PM Central Time per Stevens Point, WI

Thank you for your payment. Note: Any amount paid in excess of the remaining balance/term premium may result
in a refund.

If you have questions, please contact Customer Service at Help@DairylandInsurance.com or 1-800-334-0090.

GN1503-0915 Page 1 of 1
 PREMIUM MUST BE PAID FOR COVERAGE TO BE IN FORCE

My.DairylandInsurance.com

WASHINGTON AUTOMOBILE IN CASE OF AN ACCIDENT

INSURANCE IDENTIFICATION CARD Obtain the following information...
Patriot General Insurance Company NAIC 23442 1. Name and address of each driver, passenger and
witness.
Named Non-Owner Policy 2. Name of insurance company and policy number for
Policy 11410386740 each vehicle involved.

Fold Here
Effective Date 07/08/2025
Expiration Date 01/08/2026 THE COVERAGES LISTED ON THE DECLARATIONS PAGE
APPLY FOR ONLY THE NAMED INSURED WHILE DRIVING
NON-OWNED CARS. COVERAGE DOES NOT APPLY WHEN
Named Insured(s) DRIVING A NON - OWNED CAR AVAILABLE FOR REGULAR
MICLESCU, GHEORGHE USE BY THE NAMED INSURED.
2226 Eastlake Ave E PMB 236
Seattle WA 98102 COVERAGE COMPLIES WITH MINIMUM AMOUNT OF

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

LIABILITY INSURANCE REQUIRED. THIS CARD SERVES AS

GNA3020-0915
SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL
RESPONSIBILITY.
Agency Agency Phone 425-821-6084 YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR
Freeway Insurance Services America LLC POSSESSION AND PRODUCE IT UPON DEMAND.
7711 Center Ave Ste 200
Huntington Beach CA 92647 THIS CARD IS NOT PART OF YOUR POLICY AND IS
EFFECTIVE ONLY WHILE YOUR INSURANCE REMAINS IN
FORCE. THIS CARD NEITHER AFFIRMATIVELY NOR
If you are in an accident, call us as soon as possible at NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
1-800-334-0090. We are available 24 hours a day to take your COVERAGE AFFORDED BY YOUR POLICY.
call. See reverse side for additional information.

WASHINGTON AUTOMOBILE IN CASE OF AN ACCIDENT

INSURANCE IDENTIFICATION CARD Obtain the following information...
Patriot General Insurance Company NAIC 23442 1. Name and address of each driver, passenger and
witness.
Named Non-Owner Policy 2. Name of insurance company and policy number for
Policy 11410386740 each vehicle involved.
Fold Here

Effective Date 07/08/2025

Expiration Date 01/08/2026 THE COVERAGES LISTED ON THE DECLARATIONS PAGE
APPLY FOR ONLY THE NAMED INSURED WHILE DRIVING
NON-OWNED CARS. COVERAGE DOES NOT APPLY WHEN
Named Insured(s) DRIVING A NON - OWNED CAR AVAILABLE FOR REGULAR
MICLESCU, GHEORGHE USE BY THE NAMED INSURED.
2226 Eastlake Ave E PMB 236
Seattle WA 98102 COVERAGE COMPLIES WITH MINIMUM AMOUNT OF
LIABILITY INSURANCE REQUIRED. THIS CARD SERVES AS
GNA3020-0915

SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.
Agency Agency Phone 425-821-6084 YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR
Freeway Insurance Services America LLC POSSESSION AND PRODUCE IT UPON DEMAND.
7711 Center Ave Ste 200
Huntington Beach CA 92647 THIS CARD IS NOT PART OF YOUR POLICY AND IS
EFFECTIVE ONLY WHILE YOUR INSURANCE REMAINS IN
FORCE. THIS CARD NEITHER AFFIRMATIVELY NOR
If you are in an accident, call us as soon as possible at NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
1-800-334-0090. We are available 24 hours a day to take your COVERAGE AFFORDED BY YOUR POLICY.
call. See reverse side for additional information.
 SR-22 AAMVA UNIFORM FINANCIAL RESPONSIBILITY FORM
NAME MICLESCU, GHEORGHE
Insured { Last First Middle

ADDRESS 2226 Eastlake Ave E PMB 236 Seattle WA 98102

CASE NUMBER DRIVER'S LICENSE NUMBER BIRTH DATE SOCIAL SECURITY NO.
WDL18343213B 01/09/1989
CURRENT POLICY NUMBER 11410386740 EFFECTIVE FROM 07/08/2025
This certification is effective from 07/08/2025 and continues until cancelled or terminated in accordance with the financial
responsibility laws and regulations of this State.
The insurance hereby certified is provided by an:
OWNER'S POLICY: Applicable to (a) the following described vehicle(s), (b) any replacement(s) thereof by similar
classification, and (c) any additionally acquired vehicles of similar classification for a period of at least 30 days from the
date of acquisition.
MODEL YEAR TRADE NAME IDENTIFICATION NUMBER
NAMED NONOWNER POLICY

X OPERATOR'S POLICY: Applicable to any non-owned vehicle.

Washington

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

State FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE
The Company signatory hereto hereby certifies that it has issued to the above named insured a motor vehicle liability policy as required by
the financial responsibility laws of this State, which policy is in effect on the effective date of this certificate.
Name of Insurance Company Patriot General Insurance Company 340

Date 07/08/2025 By
SIGNATURE OF AUTHORIZED REPRESENTATIVE

OSR-22-1007 THE FACE OF THIS DOCUMENT CONTAINS A WATERMARK LOGO.

SR-22 AAMVA UNIFORM FINANCIAL RESPONSIBILITY FORM

NAME MICLESCU, GHEORGHE
Insured { Last First Middle

ADDRESS 2226 Eastlake Ave E PMB 236 Seattle WA 98102

CASE NUMBER DRIVER'S LICENSE NUMBER BIRTH DATE SOCIAL SECURITY NO.
WDL18343213B 01/09/1989
CURRENT POLICY NUMBER 11410386740 EFFECTIVE FROM 07/08/2025
This certification is effective from 07/08/2025 and continues until cancelled or terminated in accordance with the financial
responsibility laws and regulations of this State.
The insurance hereby certified is provided by an:
OWNER'S POLICY: Applicable to (a) the following described vehicle(s), (b) any replacement(s) thereof by similar
classification, and (c) any additionally acquired vehicles of similar classification for a period of at least 30 days from the
date of acquisition.
MODEL YEAR TRADE NAME IDENTIFICATION NUMBER
NAMED NONOWNER POLICY

X OPERATOR'S POLICY: Applicable to any non-owned vehicle.

State Washington FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE

The Company signatory hereto hereby certifies that it has issued to the above named insured a motor vehicle liability policy as required by
the financial responsibility laws of this State, which policy is in effect on the effective date of this certificate.
Name of Insurance Company Patriot General Insurance Company 340

Date 07/08/2025 By
SIGNATURE OF AUTHORIZED REPRESENTATIVE

OSR-22-1007 THE FACE OF THIS DOCUMENT CONTAINS A WATERMARK LOGO.

Patriot General Insurance Company

My.DairylandInsurance.com

THIRD PARTY DATA DISCLOSURE

Patriot General Insurance Company uses third parties to obtain data which allows for proper rating and
underwriting of each policy.

The following third parties may have provided information applicable to your policy:
LexisNexis® Consumer Center PO Box 105108 1-800-456-6004
Atlanta, GA 30348-5108

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

You have the right to dispute the data provided by these sources by contacting them directly.
GN1112-0915 (Policy Number 11410386740)

Page 1 of 1
 VERN FONK INSURANCE SERVICES, INC.
WASHINGTON STATE
WAIVER AND DISCLOSURE

BROAD FORM NAMED OPERATOR ENDORSEMENT

***ACKNOWLEDGEMENT***
I, the undersigned, acknowledge I have been made aware of the following coverage’s and exclusions provided by
a Broad Form Named Operator Endorsement.

Initial____ I am only insured for any motor vehicle, owned or non-owned, that is driven by me and

Initial____ Any non-owned motor vehicle that I drive must be with the permission of the owner.

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Initial____ I am not insured for any motor vehicle being used for hire.

Initial____ I am not insured for any motor vehicle being used in any business or commercial occupation.

Initial____ I am not insured for motor cycles, motor scooters or motorized bicycles.

Initial____ I understand this policy is excess over any other policy on the car that I am driving.

Initial____ I am NOT insured in the event that someone other than myself, including a spouse, is driving a
car owned by me.

Initial____ I understand there is NO insurance for physical damage (comp/coll) on any car non-owned,
being driven by me.

Initial____ I understand that I am purchasing LIABILITY LIMITS of : 25,000/50,000/10,000

and that higher limits of liability are available for purchase for additional premium. The Vern
Fonk Insurance Services Inc encourages the purchase of higher limits of liability.
Initial____ PERSONAL INJURY PROTECTION/MEDICAL has been explained to me and I DO NOT wish to
purchase this
coverage. I understand that I may purchase this coverage in the future for an additional
premium.
Initial____ UN/UNDERINSURED MOTORIST for BODILY INJURY has been explained to me and I DO
NOT wish to
purchase this coverage.
Initial____ UN/UNDERINSURED MOTORIST PROPERTY DAMAGE has been explained to me and I DO
NOT wish to
purchase this coverage. Coverage may be available for an additional premium.
Initial____ MOTOR CLUB/TOWING/ROADSIDE ASSISTANCE has been explained to me and I DO NOT
wish to purchase
this coverage.
_________________________________________________________________
**WASHINGTON STATE AGENT/PRODUCER DISCLOSURE STATEMENT***
Initial ______ The base commission the agency earns is up to 18% of the premium of $__717.46____per term
IF the premiums are paid by the insured. The agency could receive additional incentive compensation from the
insurer based on agency experience in
sales volume, growth, profitability and retention of business with National General Insurance (Insurance
Company). For additional information on the nature or amount of our compensation or our service, please
inquire.

This policy includes a $60.00 Agency Fee or a rewrite Agency Fee of $45.00. If an SR22 is required, there will be
a $50.00 fee which has already been figured into the quote that was given to you. There shall also be a
fee for $7 for any payment submitted in an office and $15 fee for an endorsement. All Agency Fees are fully
earned and non-refundable. Your signature below acknowledges the Agency Fee charge and agency
compensation.

_________________________________________________________________________________
______
***ACKNOWLEDGEMENT***

Initial ___na__ I have been offered the option to purchase Accidental Death and I choose $___________ limit in

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

coverage.

Initial _____ I have been offered the option to purchase Accidental Death and I decline to purchase it.
________________________________________________________________________

INSURED’S NAME Gheorghe Miclescu

INSURED’S SIGNATURE _________________________ DATE 7/8/2025

 SR-22
State Responsibility form #22
Financial Responsibility Waiver

The SR-22 is a Proof of Insurance form that is required by the State Department of Licensing when an
individual is sentenced by the court system as a punishment for any number of driving offenses.

SR-22 is used to inform the police if your insurance policy is active when/if you get pulled over.

This probationary sentence requires you to maintain liability insurance in order for you to maintain a
valid license for a period of three years.

If at any time your insurance is canceled for any reason the Department of Licensing requires that
your insurance company report this cancellation to them using the SR-26 form. At that time, the

Gheorghe Miclescu eSign: 7/8/2025 1:46 PM EDT, IP: 2607:fb90:bb0a:c1f0:19b7:1075:a379:4592

Department of Licensing will again mark your license as suspended in their system and send you a
notification in the mail (using the address on your driver’s license) that your driver’s license has been
suspended.

If you have been granted an IIL (Ignition Interlock License) and your insurance company files a SR-26
canceling your SR-22, your IIL will be cancelled and you will have to reapply and pay the $100
application fee again. It is important that your insurance payments be made on time.

If at any time you are caught driving without your SR-22 on file with the Department of Licensing:
* You can be arrested for driving while suspended
* Your car can be impounded
* You will be ticketed for driving while suspended
* You will be ticketed for No Proof of Liability

By signing below you acknowledge and understand that maintaining a valid license is your
responsibility. Therefore you will be held responsible for any and all fines, penalties,
inconveniences or other repercussions due to being stopped without a valid license.

_________________________ 7/8/2025

Applicant Signature Date