MGA INSURANCE COMPANY, INC.

BROKERING AGENT'S REGISTER NO:

PRODUCER NO: A47296
Name: S QUINONES INC
P.O. Box 199023, Dallas, TX 75219-9022
Phone: 800-526-8016 Fax: 800-532-3522 Address: 4422 W HWY 40 #1
City, State, Zip: OCALA, FL 34482
AUTOMOBILE QUOTE POLICY NO: 12MGEP0566117-00

APPLICANT: MAILING ADDRESS: PREVIOUS INS.CO. & POLICY NO.:

DANHOE MEDINA (IF DIFFERENT FROM GARAGING ADDRESS)
PRIOR COVERAGE: No
EXPIRATION DATE:
GARAGING ADDRESS: COVERAGE LIMITS:
9149 MELLOW CORAL ST DAYS LAPSED:
CITY, STATE, ZIP: CITY, STATE, ZIP: TELEPHONE NO.:
WINTER GARDEN, FL 34787 (Attach Proof for Credit)
HOME PHONE: (407)702 - 0408 HOME OWNER: YES NO PAYMENT OPTION
MOBILE HOME: YES NO
WORK PHONE: Time at Residence: ____
1 yrs _____months
0 Down Payment $227.50 5 X $ 136.37
EFFECTIVE DATE OF COVERAGE DOWN PAYMENT
POLICY EFFECTIVE: 12:01 am FROM: 04/17/2023 TO: 10/17/2023 AMOUNT: $ 227.50
COVERAGES LIMITS AND DEDUCTIBLES AUTO 1 AUTO 2 AUTO 3 AUTO 4 AUTO 5 AUTO 6
BODILY INJURY LIABILITY / Each Person/Accident
PROPERTY DAMAGE LIABILITY 10000 Each Accident $232.00
PERSONAL INJURY PROTECTION* Statutory 1000 Deductible $613.00
MEDICAL PAYMENTS
UNINSURED MOTORIST* / Each Person/Accident
1) 2) 3) 4) 5) 6)
COMPREHENSIVE ACV
1) 2) 3) 4) 5) 6)
COLLISION OR UPSET ACV
1) 2) 3) 4) 5) 6)
RENTAL REIMBURSEMENT (Per Day/Max)
1) 2) 3) 4) 5) 6)
TOWING AND LABOR (Per Occurrence)
1) 2) 3) 4) 5) 6)
CUSTOM OR ADDITIONAL EQUIPMENT
* Refer to pages 4 and 5 of this application for your options for TOTAL PREMIUM PER AUTO
Personal Injury Protection and Uninsured Motorist coverages. AUTO 1 AUTO 2 AUTO 3 AUTO 4 AUTO 5 AUTO 6
A Preinsurance Inspection Form must be completed for each vehicle $845.00
purchasing comprehensive or collision coverage. I understand that I am
SR-22 FILING FEE
applying for the coverages indicated above for the vehicle(s) and driver(s)
listed on this application. I further understand there is no coverage under POLICY FEE $25.00
this binder application unless indicated on the coverage section and
unless a premium has been charged for that specific coverage. INSTALLMENT SET UP CHARGE $10.00
FIGA FEE
FLORIDA HURRICANE CATASTROPHE FUND
USE CODES: P = Pleasure Use W = To/From Work S = To/From School A = Artisan B = Business Use $880.00
If Use Code "A" or "B" is selected, then attach completed "SUPPLEMENTAL ARTISAN/BUSINESS USE APPLICATION" TOTAL

YEAR MAKE MODEL USE VIN Number

1 2006 TYTA SIENNA VAN 2WD W 5TDZA23C06S580488
Garage Address: 9149 MELLOW CORAL ST Lienholder:
WINTER GARDEN, FL 34787 Additional Interest:
2
Garage Address: Lienholder:
Additional Interest:
3
Garage Address: Lienholder:
Additional Interest:
4
Garage Address: Lienholder:
Additional Interest:
5
Garage Address: Lienholder:
Additional Interest:
6
Garage Address: Lienholder:
Additional Interest:
1201 FL (01/13) Page 1 of 6
DRIVER AND RESIDENT INFORMATION - Persons required to be listed on this Application
List all persons 14 years or older, licensed or not, residing with the applicant(s), whether or not they drive/operate the listed vehicle(s). List all regular or occasional operators
of said vehicle(s). List any children or dependents of the applicant or applicant's spouse, between the age of 14 and 21, regardless of whether they reside with the
applicant(s). If the person has never been licensed, or if the license has been permanently surrendered and they do not drive, they may be listed as an Unlicensed Resident;
otherwise they must be listed as a driver. If the person has ever held a Florida driver's license, that license must be entered as the driver's license information.

FAILURE TO LIST ALL SUCH PERSONS AS DESCRIBED ABOVE MAY CONSTITUTE A MATERIAL MISREPRESENTATION,
WHICH MAY RESULT IN ALL INSURANCE COVERAGES BEING VOID
.
APPLICANT RELATION DRIVER BIRTH DATE GENDER MARITAL SR-22 CASE DRIVER'S LICENSE
(MM.DD.YY) STATUS SR-22 NUMBER NUMBER
1 DANHOE MEDINA Insured X Y N 10/09/1990 M S Y X N 180203160103
2 Y N Y N
3 Y N Y N
4 Y N Y N
5 Y N Y N
6 Y N Y N
7 Y N Y N
8 Y N Y N

ADDITIONAL DRIVER INFORMATION

Please explain if the answer to either question is "NO" YES NO
Have all people described above been listed on the application? X

Has the Florida license information been entered for all Drivers who have held a Florida license? X

I declare the following:

I have listed all residents of my household on the application for insurance, including but not limited to relatives, friends, tenants, or anyone who lives at my
place of residence. I have listed all regular or occasional operators, licensed or permitted, and who may or may not reside in my household, on the
application for insurance. I understand that operators include those persons whose driving privileges are currently restricted, suspended, revoked, or who
are not licensed and drive my vehicle(s).

April 17, 2023

E-SIGNED by DANHOE MEDINA
Signature of Applicant: on 2023-04-17 17:47:24 GMT Date:

NAMED DRIVER EXCLUSION WARNING:

Do NOT use the Named Driver Exclusion on any application with a proof of financial responsibility filing.
I authorize the person(s) listed below to be excluded from my insurance policy. This means that none of the coverage, except Personal Injury Protection and
Property Damage Liability afforded by my policy, will apply to any damage, losses or claims of any person(s) or organization(s) caused while any motor
vehicle insured by this policy is being operated by the excluded driver(s) listed below. Coverage for claims under Property Damage Liability arising from an
accident or loss that occurs while a vehicle is being operated by the excluded driver(s) shall be limited to $10,000. This exclusion applies regardless of any
provisions in the auto policy defining insured persons. I understand that this agreement will be binding and will apply to all future renewals, reinstatements,
and changes in policy unless I notify the Company otherwise in writing.
NAME OF EXCLUDED DRIVER DATE OF BIRTH RELATIONSHIP TO APPLICANT
OLLYVICE LUGO 09/12/1965 Relative

Date: April 17, 2023

E-SIGNED by DANHOE MEDINA
Signature of Applicant: on 2023-04-17 17:47:26 GMT

THE DRIVING RECORD AND ALL CLAIMS HISTORY FOR ALL DRIVERS, RESIDENTS, VEHICLES, AND THEIR RESPECTIVE PRIOR AUTO INSURANCE POLICIES
ARE LISTED BELOW FOR THE PREVIOUS 36 MONTHS. THE INFORMATION WAS OBTAINED FROM ONE OF THE FOLLOWING SOURCES: - APPLICANT (APP) -
MOTOR VEHICLE REPORT (MVR) - LOSS HISTORY REPORT (LHR) - CLAIMS HISTORY WITH A GAINSCO COMPANY (GAN)

DRIVER DATE DESCRIPTION SOURCE APPLICANT AWARE

OF THIS INCIDENT?

1201 FL (01/13) Page 2 of 6

 NOTICE TO APPLICANT: READ THIS SECTION CAREFULLY. EXPLAIN ALL "YES" ANSWERS IN REMARKS.
1. Has any listed driver had their driver's license or vehicle registration suspended, revoked or refused in the last 36 months? X NO
YES
2. Are any of the vehicles listed on this application registered to anyone other than the applicant (Named Insured), or the X NO
spouse of the applicant? YES
3. Are any vehicles listed on this application used for hire, commercial or business purposes, delivery, or in the course or X NO
scope of your employment? YES
4. Is there existing damage to any vehicle? X NO
YES
5. How many personal auto injury claims have you or any resident member of your household been involved in during the last
36 months? 0

REMARKS: (Include reference to vehicle and driver for each explanation)

I have read each of the questions (numbered 1 - 5 ) above and answered all questions truthfully. I realize that any false
information may constitute a material misrepresentation.

E-SIGNED by DANHOE MEDINA

Signature of Applicant: on 2023-04-17 17:47:31 GMT Date:
April 17, 2023

CUSTOM OR ADDITIONAL EQUIPMENT

DESCRIPTION AND VALUE OF ADDITIONAL EQUIPMENT
VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4 VEHICLE 5 VEHICLE 6
CUSTOM PAINT
CUSTOM WHEELS
PHONE EQUIPMENT
STEREO/SOUND EQUIPMENT
VIDEO EQUIPMENT
NAVIGATION / GPS
TOTAL

FRAUD STATEMENT
In an effort to keep insurance costs down for our policy holders, the company actively investigates and pursues the prosecution of
persons who commit insurance fraud.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT
OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY OF THE THIRD DEGREE.

E-SIGNED by DANHOE MEDINA

on 2023-04-17 17:47:33 GMT April 17, 2023
Signature of Applicant: Date:

1201 FL (01/13) Page 3 of 6

 UNINSURED MOTORIST COVERAGE ACKNOWLEDGEMENT - 1201FL UM (05/11)

YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU
AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR
BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY.
Uninsured Motorist Coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor
vehicles because of bodily injury or death resulting therefrom. Such benefits may include payments for certain medical expenses, lost
wages, and pain and suffering, subject to limitations and conditions contained in the policy. For the purpose of this coverage, an
uninsured motor vehicle may include a motor vehicle as to which the bodily injury liability limits are less than your damages.
Florida law requires that automobile liability policies include Uninsured Motorist Coverage at limits equal to the Bodily Injury Liability limits
in your policy unless you select a lower limit offered by the Company, or reject Uninsured Motorist Coverage entirely. Please indicate
whether you desire to entirely reject Uninsured Motorist Coverage, or whether you desire this coverage at limits lower than the Bodily
Injury Liability limits of your policy:

X a. I hereby reject Uninsured Motorist Coverage.

b. I hereby select Uninsured Motorist Coverage limits of _______________________, which are lower than my
Bodily Injury Liability limits.

I understand and agree to the selection of any of the above options to my liability insurance policy, and understand that these
selections apply to this policy, future renewals, reinstatements or replacements of such policy which are issued at the same Bodily Injury
Liability limits. If I decide to select another option at some future time, I must tell the Company or my agent in writing.

E-SIGNED by DANHOE MEDINA

on 2023-04-17 17:47:36 GMT April 17, 2023
Signature of Applicant: Date:

ELECTION OF NON-STACKED COVERAGE

(Do not complete if you have rejected Uninsured Motorist Coverage)
You have the option to purchase, at a reduced rate, a non-stacked (limited) type of Uninsured Motorist coverage. Under this form, if injury
occurs in a vehicle owned or leased by you or any family member who resides with you, this policy will apply only to the extent of coverage
(if any) which applies to that vehicle in this policy. If any injury occurs while occupying someone else's vehicle or you are struck as a
pedestrian, you are entitled to select the highest limits of Uninsured Motorist Coverage available on any one vehicle for which you are a
named insured, insured family member, or insured resident of the named insured's household. This policy will not apply if you select the
coverage available under any other policy issued to you or the policy of any other family member who resides with you. If you do not elect to
purchase the non-stacked form, your policy limit(s) for each motor vehicle are added together (stacked) for all covered injuries. Thus, your
policy limits would automatically change during the policy term if you increase or decrease the number of autos covered under the policy.

I hereby elect the non-stacked form of Uninsured Motorist Coverage.

I understand and agree to the selection of any of the above options to my liability insurance policy, future renewals, reinstatements
or replacements of such policy which are issued at the same Bodily Injury Liability Limits. If I decide to select another option at some future
time, I must tell the Company or my agent in writing.

Signature of Applicant: N/A Date:

1201 FL (01/13) Page 4 of 6

 PERSONAL INJURY PROTECTION
I UNDERSTAND THAT I MAY PURCHASE THE FOLLOWING COVERAGE WITH ANY OF THE
DEDUCTIBLES / WORK LOSS OPTIONS INDICATED AND RECEIVE A REDUCTION IN PREMIUM.
No-Fault Personal Injury Protection (PIP) is mandatory, but the following options are available to you to prevent duplication with other
private plans or benefit programs.
Deductible Options: $250 $500 X $1,000 No Deductible
Applies to: X Named Insured and Dependent Resident Relatives (NIRR) Named Insured Only (IO)
Work Loss Options: I elect to exclude Work Loss for: Named Insured and Dependent Resident Relatives (NIRR)
Named Insured Only (IO)
For Personal Injury Protection insurance, the named insured may elect a deductible and to exclude coverage for loss of
gross income and loss of earning capacity ("lost wages"). These elections apply to the named insured alone, or to the
named insured and all dependent resident relatives. A premium reduction will result from these elections. The named
insured is hereby advised not to elect the lost wages exclusion if the named insured or dependent resident relatives are
employed, since lost wages will not be payable in the event of an accident.
IF A DEDUCTIBLE OPTION IS ELECTED FOR DEPENDENT RELATIVES, COMPLETE THE INFORMATION BELOW:
Name of Dependent Relative Date of Birth Relationship to Applicant
DANHOE MEDINA 10/09/1990 Insured
OLLYVICE LUGO 09/12/1965 Relative

In accordance with the provisions of the Florida Insurance Code, section 627.739 which requires insurers to offer certain limitations to
Personal Injury Protection Coverage, the undersigned does hereby request the limitations indicated with a X above to the Personal
Injury Protection coverage to be provided by the policy for which I/We are applying.

Signature of Applicant:
E-SIGNED by DANHOE MEDINA
on 2023-04-17 17:47:43 GMT
Date:
April 17, 2023

ADDITIONAL DISCLOSURES AND ACKNOWLEDGMENTS

The Brokering Agent has no authority to Bind the Company without first obtaining confirmation from the Company through a
TELEPHONE, FAX, or INTERNET BINDER and receiving a corresponding BINDER NUMBER. The Brokering Agent has no right to
MAKE, ALTER, MODIFY, or DISCHARGE any CONTRACT or POLICY issued on the basis of this application. I understand that this
application is not a binder unless indicated as such on this form by the Brokering Agent.

Signature of Applicant:
E-SIGNED by DANHOE MEDINA
on 2023-04-17 17:47:45 GMT Date:
April 17, 2023
This application is in compliance with Section 626.752, Florida Statutes. A copy has been furnished to the applicant or insured and
coverage is:
X Bound effective (TIME) 12:43:51 CST (DATE) 04/17/2023 Not Bound

Signature of Agent: State License #: P147941

Agent's Name: NICOLE ACEVEDO Date:

It is understood by the applicant that the premium on any policy issued on the basis of this application may be adjusted as the result of the
motor vehicle report on any operator. It is further understood that the applicant shall be responsible for any additional premium from (1)
additional coverages being added to this policy, (2) motor vehicle reports, (3) or any changes of classification which may develop.

The undersigned by signature hereto, represents the statements and answers made herein to be true, complete, and correct, and agrees
that any policy may be issued or renewed in reliance upon the truth, completeness and correctness of such statements and answers, and
understands that falsity, incompleteness, or incorrectness may jeopardize the coverage under such policy so issued or renewed. Florida
Statues 627.409.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT
OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY OF THE THIRD DEGREE.

E-SIGNED by DANHOE MEDINA

Signature of Applicant: on 2023-04-17 17:47:49 GMT Date:
April 17, 2023

1201 FL (01/13) Page 5 of 6

 APPLICANT'S STATEMENT
I hereby declare that the statements contained herein are true and do hereby agree to pay any surcharges applicable under
the Company rules which are necessitated by inaccurate statements. I hereby declare that no person(s) other than those
listed on this application regularly operate the vehicle(s) described in this application. I understand that this policy may be
rescinded and declared void if this application contains any false information or if any information that would alter the
Company's exposure is omitted or misrepresented.

I declare that as of this date I have had no claims in the past 3 years that I have not previously disclosed to this insurance
company on this application for insurance, or through an ACORD loss notice. I understand that a claim means a loss that is
covered under an insurance policy, regardless of fault, payable under any coverage, such as collision, liability, or uninsured
motorist. I realize that a false statement may be a material misrepresentation and may jeopardize any continuation of
coverages under this policy. I acknowledge that in connection with this application and premium quotation, the Company
may collect information from consumer reporting agencies, such as driving record, claims and credit history reports, and
obtain or use a credit-based insurance score based on the information contained in that credit report. The Company may
also obtain information about the vehicle(s) to be insured. This information will be used to underwrite my insurance and
provide an accurate quote. Future reports may be used to update or renew this insurance.

In accordance with the Fair Credit Reporting Act, Public Law 91-508, effective April 25, 1979, you are hereby advised that
as a part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning
character, general reputation, personal characteristics, credit history, and mode of living. Upon your request, additional
information as to the nature and scope of the report, if one is made, will be provided.
Applicant's Initials: __________
D.M.

I understand that the premium on any policy issued on the basis of this application may be adjusted as the result of the
motor vehicle report on any operator. I further understand that I shall be responsible for any additional premium from (1)
additional coverages being added to this policy, (2) motor vehicle reports, (3) or any changes of classification which may
develop.

I understand that a service charge will be assessed to the balance due on my policy if any check offered in payment is not
honored by my bank or other financial institution. I agree that if I pay my initial premium payment by check, draft, or other
remittance, the coverage afforded by this insurance is conditioned on the check, draft, or other remittance being honored by
the bank when presented for payment. If a check, draft, or other remittance is not honored, the Company shall be deemed
not to have accepted payment and this policy shall be canceled from its inception.

I agree to pay the installment fees shown on my billing statement that become due during the policy term and each renewal
policy term in accordance with the payment plan I have selected. I agree to pay a late fee during the policy term and each
renewal policy when a payment is received after the premium due date.

I (we) hereby agree and understand that any and all policy fee(s) charged hereon may be declared fully earned by the
insurance company and or underwriters. I understand that the statements and representations made on this application will
become part of my policy.

Si usted no puede leer, comprender o entender este documento, todo o en parte, es muy importante que usted
solicite ayuda de alguna persona que le puede interpretar y explicarle el contenido de este documento. (If you
cannot read, comprehend, or understand this document, all or in part it is very important that you ask for help from
some person that can interpret and explain to you the content of this document.)

Mi firma representa que este documento se me ha sido explicado y he entendido todo el contenido de este
documento. (My signature represents that this document has been explained to me and I understand all the
contents of this document.)

E-SIGNED by DANHOE MEDINA

Signature of Applicant: on 2023-04-17 17:47:53 GMT
Date: April 17, 2023

AGENT'S STATEMENT
I certify that, to the best of my knowledge, all information contained herein is correct and complete, the statements herein
are those of the applicant, this application and any attachments have in all respects been prepared in accordance with the
terms of the MGA Insurance Company, Inc. Florida Personal Auto Rule Guide, and the applicant legally signed this
application for insurance. I am legally qualified to submit this application for insurance.

Agent's Name: NICOLE ACEVEDO State License No.: P147941

Signature of Agent: Date:

1201 FL (01/13) Page 6 of 6