TEXAS Policy Number 11409240792

AUTO APPLICATION Effective Date: 02/23/2024

Dairyland County Mutual Insurance 03:35 PM Central Time per Stevens Point,
Company Of Texas WI
My.DairylandInsurance.com
DAIRYLAND 2.0-6
Named Insured(s) Agency
COLEMAN, ADRIANA Community & Family Affinity Services Inc
2000 Skyline Dr Melany Mejia
McKinney TX 75071 70 S Val Vista Dr Ste A3-687
Phone: 972-502-0046 Gilbert AZ 85296
Phone: 972-423-4348

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 $30,000 Each Person/$60,000 Each accident $151.74
Property Damage Liability $25,000 Each accident $137.94
Uninsured & Underinsured Motorist Bodily Injury Rejected
Uninsured & Underinsured Motorist Property Damage Rejected
Medical Payments Not Selected
Mexico Limited Coverage Not Selected
Personal Injury Protection Rejected
Subtotal Premium By Policy $289.68
Premium Summary
Term Premium Total (excludes fees) $289.68
New Business Policy Fee $72.00
Total Cost $361.68
Total Amount Submitted $60.26
Pay Plan 5 Installments
Automatic Payments N

Fee Information
The following fees may be charged during the life of the policy. These fees may change.
Reinstatement Renewal Policy New Business Rewrite Policy Rewrite Fee Late Fee Returned Billing Fee
Fee Fee Policy Fee Fee Payment Fee

$25.00 $72.00 $72.00 $72.00 $5.00 $5.00 $25.00 $3.00

Discount Information: None

Surcharge Information: None

Vehicle Information
Residential Zip: 75071 Named Non-Owner Policy

Driver Information
Marital License
Drv # Name Date of Birth Gender License Number Financial Responsibility
Status State
1 COLEMAN, ADRIANA 11/25/1988 F S TX ***

Accident and Violation Information: None

TXA1101-0123 (Policy # 11409240792) Page 1 of 3

Lienholder/Additional Insured/Additional Interest Information: None

Named Insured Confirmation

I understand and agree this application is a part of the policy.
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 the initial 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.
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, to the extent permitted by Texas Insurance Code sections §705.004, this policy may be
rescinded and/or coverage denied if this application contains any misrepresentations shown at trial to be material to the
risk or contributed to the contingency or event on which the policy became due and payable.
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 a fee, or for 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.
NOTIFICATION OF POSSIBLE INVESTIGATIVE REPORT - As required by Public Law 91-508, Fair Credit Reporting Act,
this is to inform you that as part of our procedure for processing and reviewing applications, new policies, renewal policies
and policies currently in effect, a credit report, motor vehicle report or an investigative report may be obtained through
personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors,
or others with whom you are acquainted. This inquiry includes information as to your character, general reputation,
personal characteristics, and mode of living or driving history, whichever may be applicable. You have the right to make a
written request to this company within a reasonable period of time for a complete and accurate disclosure of additional
information concerning the nature and scope of the investigation and/or dispute such information which you believe to be
erroneous.
I understand and agree the Company may use a credit based insurance score determined by information contained in my
credit history. I understand and agree new or updated credit 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.

TXA1101-0123 (Policy # 11409240792) Page 2 of 3

I understand and agree it is my responsibility to promptly report any change of residential location to the Company.

I HEREBY APPOINT THE PRESIDENT OF DAIRYLAND COUNTY MUTUAL INSURANCE COMPANY OF TEXAS,
WITH FULL POWER OF SUBSTITUTION, TO BE MY LAWFUL ATTORNEY IN FACT. IN MY ABSENCE HE IS HEREBY
AUTHORIZED AND EMPOWERED TO VOTE FOR ME AT ANY MEMBERSHIP MEETINGS DURING THE TERM OF
THIS POLICY AND ANY RENEWAL OR REPLACEMENT POLICY. THIS PROXY WILL REMAIN VALID FOR 11
MONTHS, UNLESS I GIVE WRITTEN NOTICE OTHERWISE.
I ACKNOWLEDGE AND AGREE THAT BY CLICKING MY NAME ON THE DESIGNATED LINE(S) INDICATING "CLICK
HERE TO SIGN", I AM ELECTRONICALLY SIGNING THIS APPLICATION, WHICH WILL HAVE THE SAME LEGAL
EFFECT AS THE EXECUTION OF THIS DOCUMENT BY A WRITTEN SIGNATURE AND SHALL BE VALID EVIDENCE
OF MY INTENT AND AGREEMENT TO BE BOUND BY ITS TERMS.
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
2/23/2024, 6:03 PM LOCAL TIME
{{ Dte_es_:signer1:dimension(width=70mm, height=8mm):font(size= 10) :calc(now( )):format(date,'m/d/yyyy, h:nn tt " LOCAL TIME"') }}
PM *
Adriana Coleman
({{Sig_es_:signer1:signature:dimension(width=50mm, height=8mm)}})

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
PM *
Date Signed Time Signed Producer's Signature

TXA1101-0123 (Policy # 11409240792) Page 3 of 3

Dairyland County Mutual Insurance Company Of Texas

My.DairylandInsurance.com

TEXAS PERSONAL INJURY PROTECTION COVERAGE REJECTION

AND LIMITED POWER OF ATTORNEY
I understand and hereby reject Personal Injury Protection Coverage as provided in Texas Insurance Code § 1952.
Further, I appoint Dairyland County Mutual Insurance Company Of Texas to be lawful Attorney-in-fact to continue this
rejection of Personal Injury Protection Coverage on all subsequent renewals or rewrites of this policy, unless and not until
I request this coverage in writing.
I ACKNOWLEDGE AND AGREE THAT BY CLICKING MY NAME ON THE DESIGNATED LINE(S) INDICATING "CLICK
HERE TO SIGN", I AM ELECTRONICALLY SIGNING THIS DOCUMENT, WHICH WILL HAVE THE SAME LEGAL
EFFECT AS THE EXECUTION OF THIS DOCUMENT BY A WRITTEN SIGNATURE AND SHALL BE VALID EVIDENCE
OF MY INTENT AND AGREEMENT TO BE BOUND BY ITS TERMS.
Adriana Coleman 2/23/2024, 6:03 PM LOCAL TIME
({{Sig_es_:signer1:signature:dimension(width=50mm, height=8mm)}}) {{ Dte_es_:signer1:dimension(width=70mm, height=8mm):font(size= 10) :calc(now( )):format(date,'m/d/yyyy, h:nn tt " LOCAL TIME"') }}

Named Insured's Signature Date

TXPIP-0317 (Pol #11409240792) Page 1 of 1

Dairyland County Mutual Insurance Company Of Texas

My.DairylandInsurance.com

TEXAS UNINSURED/UNDERINSURED MOTORISTS COVERAGE REJECTION

I have been given the opportunity to purchase or to reject as provided in Texas Insurance Code § 1952. I make the
following choice:

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

X I reject Uninsured/Underinsured Motorists Property Damage (UM/UIM-PD) Coverage in its entirety.

I fully understand UM/UIM-BI and UM/UIM-PD Coverage. I 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. I also understand this rejection applies to all vehicles
insured under my policy. I understand I may add this coverage to my policy at a future date.
I ACKNOWLEDGE AND AGREE THAT BY CLICKING MY NAME ON THE DESIGNATED LINE(S) INDICATING "CLICK
HERE TO SIGN", I AM ELECTRONICALLY SIGNING THIS APPLICATION, WHICH WILL HAVE THE SAME LEGAL
EFFECT AS THE EXECUTION OF THIS DOCUMENT BY A WRITTEN SIGNATURE AND SHALL BE VALID EVIDENCE
OF MY INTENT AND AGREEMENT TO BE BOUND BY ITS TERMS.
Adriana Coleman 2/23/2024, 6:03 PM LOCAL TIME
({{Sig_es_:signer1:signature:dimension(width=50mm, height=8mm)}}) {{ Dte_es_:signer1:dimension(width=70mm, height=8mm):font(size= 10) :calc(now( )):format(date,'m/d/yyyy, h:nn tt " LOCAL TIME"') }}

Named Insured's Signature Date

TXUM-0317 (Pol #11409240792) Page 1 of 1

Dairyland County Mutual Insurance Company Of Texas

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 that no coverage is afforded to me under this
policy if I am using a vehicle I own or have regular use of or that I may use for business purposes. I further
acknowledge no coverage is provided under this policy for damage to any vehicle I am using.

I ACKNOWLEDGE AND AGREE THAT BY CLICKING MY NAME ON THE DESIGNATED LINE(S) INDICATING "CLICK
HERE TO SIGN", I AM ELECTRONICALLY SIGNING THIS DOCUMENT, WHICH WILL HAVE THE SAME LEGAL
EFFECT AS THE EXECUTION OF THIS DOCUMENT BY A WRITTEN SIGNATURE AND SHALL BE VALID EVIDENCE
OF MY INTENT AND AGREEMENT TO BE BOUND BY ITS TERMS.

Adriana Coleman 2/23/2024, 6:03 PM LOCAL TIME

({{Sig_es_:signer1:signature:dimension(width=50mm, height=8mm)}}) {{ Dte_es_:signer1:dimension(width=70mm, height=8mm):font(size= 10) :calc(now( )):format(date,'m/d/yyyy, h:nn tt " LOCAL TIME"') }}

Named Insured's Signature Date

TX1006-0419 (Pol #11409240792) Page 1 of 1

 PREMIUM MUST BE PAID FOR COVERAGE TO BE IN FORCE

My.DairylandInsurance.com

Vehicle(s) Covered Texas Liability Insurance Card

Year / Año Make / Marca de Model / Modelo
Insurance Company / Compañia de Seguro
VIN / Nùmero de Vehiculo Dairyland County Mutual Insurance Company Of Texas
NON-OWNED CARS USED BY NAME Information Number 1-800-334-0090
INSURED ONLY Policy Number / Effective Date/Fecha Efectiva
Nùmero de Pòliza 02/23/2024
Driver(s) Covered 11409240792 Expiration Date/Fecha de Expiraciòn
COLEMAN, ADRIANA 08/23/2024
Year / Año Make / Marca de Model / Modelo
VIN / Nùmero de Vehiculo
NON-OWNED CARS USED BY NAME INSURED ONLY
Agency / Agencia Agency /Agencia Phone #
Community & Family Affinity Services 972-423-4348
Inc
70 S Val Vista Dr Ste A3-687
Gilbert AZ 85296

Name and Address of Insured / Nombre y Direcciòn del Asegurado

COLEMAN, ADRIANA
2000 SKYLINE DR
MCKINNEY TX 75071

This policy provides at least the minimum amounts of liability insurance required
by the Texas Motor Vehicle Safety Responsibility Act for the specified vehicles
and named insureds and may provide coverage for other persons and vehicles
as provided by the insurance policy.
This is part of your identification card, do not Fold Here TXA3020-0317
detach.

Tarjeta de Seguro de Texas Liability Insurance Card

Responsabilidad Civil de Texas Keep this card.
Guarde esta tarjeta.
IMPORTANTE: Usted debe mostrar esta IMPORTANT: You must show this card or a copy of your insurance
tarjeta o una copia de su póliza de seguro policy when you apply for or renew your:
cuando solicite o renueve su: • Motor vehicle registration
• Registro del vehículo motorizado • Driver's license
• Licencia de conducir • Motor vehicle safety inspection sticker.
• Etiqueta de inspección de segurida para You may also be asked to show this card or your policy if you have an
su vehículo. accident or if a peace officer asks to see it.
También se puede pedir que usted muestre All drivers in Texas must carry liability insurance on their vehicles or
esta tarjeta o su póliza si tiene un accidente o otherwise meet legal requirements for financial responsibility. If you do
si se la pide un oficial de policía. not meet your financial responsibility requirements, you could be fined
Todos los conductores en Texas deben de up to $1,000, your driver's license and motor vehicle registration could
tener seguro de responsabilidad para sus be suspended, and your vehicle could be impounded for up to 180 days
vehiculos o de otra manera llenar los requistos (at a cost of $15 per day).
legales de responsabilidad civil. Fallo en llenar THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY
este requisto pudiera resultar en multas de WHILE YOUR INSURANCE REMAINS IN FORCE. THIS CARD NEITHER
hasta $1,000, suspensiòn de su licencia para AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
conducir y su registro de vehiculo de motor, y COVERAGE AFFORDED BY YOUR POLICY.
la retenciòn de su vehiculo por unperiodo de
hasta 180 dias (a un costo de $15 por dia).
 PREMIUM MUST BE PAID FOR COVERAGE TO BE IN FORCE

My.DairylandInsurance.com

Vehicle(s) Covered Texas Liability Insurance Card

Year / Año Make / Marca de Model / Modelo
Insurance Company / Compañia de Seguro
VIN / Nùmero de Vehiculo Dairyland County Mutual Insurance Company Of Texas
NON-OWNED CARS USED BY NAME Information Number 1-800-334-0090
INSURED ONLY Policy Number / Effective Date/Fecha Efectiva
Nùmero de Pòliza 02/23/2024
Driver(s) Covered 11409240792 Expiration Date/Fecha de Expiraciòn
COLEMAN, ADRIANA 08/23/2024
Year / Año Make / Marca de Model / Modelo
VIN / Nùmero de Vehiculo
NON-OWNED CARS USED BY NAME INSURED ONLY
Agency / Agencia Agency /Agencia Phone #
Community & Family Affinity Services 972-423-4348
Inc
70 S Val Vista Dr Ste A3-687
Gilbert AZ 85296

Name and Address of Insured / Nombre y Direcciòn del Asegurado

COLEMAN, ADRIANA
2000 SKYLINE DR
MCKINNEY TX 75071

This policy provides at least the minimum amounts of liability insurance required
by the Texas Motor Vehicle Safety Responsibility Act for the specified vehicles
and named insureds and may provide coverage for other persons and vehicles
as provided by the insurance policy.
This is part of your identification card, do not Fold Here TXA3020-0317
detach.

Tarjeta de Seguro de Texas Liability Insurance Card

Responsabilidad Civil de Texas Keep this card.
Guarde esta tarjeta.
IMPORTANTE: Usted debe mostrar esta IMPORTANT: You must show this card or a copy of your insurance
tarjeta o una copia de su póliza de seguro policy when you apply for or renew your:
cuando solicite o renueve su: • Motor vehicle registration
• Registro del vehículo motorizado • Driver's license
• Licencia de conducir • Motor vehicle safety inspection sticker.
• Etiqueta de inspección de segurida para You may also be asked to show this card or your policy if you have an
su vehículo. accident or if a peace officer asks to see it.
También se puede pedir que usted muestre All drivers in Texas must carry liability insurance on their vehicles or
esta tarjeta o su póliza si tiene un accidente o otherwise meet legal requirements for financial responsibility. If you do
si se la pide un oficial de policía. not meet your financial responsibility requirements, you could be fined
Todos los conductores en Texas deben de up to $1,000, your driver's license and motor vehicle registration could
tener seguro de responsabilidad para sus be suspended, and your vehicle could be impounded for up to 180 days
vehiculos o de otra manera llenar los requistos (at a cost of $15 per day).
legales de responsabilidad civil. Fallo en llenar THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY
este requisto pudiera resultar en multas de WHILE YOUR INSURANCE REMAINS IN FORCE. THIS CARD NEITHER
hasta $1,000, suspensiòn de su licencia para AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
conducir y su registro de vehiculo de motor, y COVERAGE AFFORDED BY YOUR POLICY.
la retenciòn de su vehiculo por unperiodo de
hasta 180 dias (a un costo de $15 por dia).
Action Required - Dairyland® Insurance Policy
11409240792 for ADRIANA COLEMAN
Final Audit Report 2024-02-24

Created: 2024-02-23

By: Dairyland Electronic Signatures (electronicsignatureind@dairylandinsurance.com)

Status: Signed

Transaction ID: CBJCHBCAABAAc5JLAtsA80snPXccVc1Q6RpXLPonCuuL

"Action Required - Dairyland® Insurance Policy 11409240792 fo

r ADRIANA COLEMAN" History
Document created by Dairyland Electronic Signatures (electronicsignatureind@dairylandinsurance.com)
2024-02-23 - 9:36:10 PM GMT- IP address: 157.248.216.2

Document emailed to colemanadriana6109@gmail.com for signature

2024-02-23 - 9:36:14 PM GMT

Email viewed by colemanadriana6109@gmail.com

2024-02-23 - 9:43:26 PM GMT- IP address: 66.249.80.102

Signer colemanadriana6109@gmail.com entered name at signing as Adriana Coleman

2024-02-24 - 0:03:41 AM GMT- IP address: 67.11.177.28

Adriana Coleman (colemanadriana6109@gmail.com) has explicitly agreed to the terms of use and to do
business electronically with Sentry Insurance Group
2024-02-24 - 0:03:43 AM GMT- IP address: 67.11.177.28

Document e-signed by Adriana Coleman (colemanadriana6109@gmail.com)

Signature Date: 2024-02-24 - 0:03:43 AM GMT - Time Source: server- IP address: 67.11.177.28

Agreement completed.
2024-02-24 - 0:03:43 AM GMT