Binder For State Farm Automobile Insurance

Policy Number:757 6688-C10-35

Policy Owners (Named Insureds) Agent
Corpus, Benjamin
Clifford L Kulp
1717 Bethel Rd
Columbus, OH 43220-1884

Mailing Address
COLUMBUS, OH 432203199

Vehicle Application
Year:2001 Effective date:03-10-2012
Make:DODGE Application date:03-10-2012
Model:INTREPID Application time:02:14:15 PM CST
Body Style:"SE" 4D SED GAS

The premium shown below must be in compliance with the Company's rules and rates and is subject to revision. The premium amounts shown below do not include the additional fees required if the monthly payment plan was selected.

Coverage Applied For Limits/Deductibles (* denotes thousands) Six Month Premium
Liability - Bodily Injury / Property Damage$15/$30/$10 * $225.70

Total 6 month premium -- $225.70
Payment received- $225.70
Balance due$0.00

Premium adjustments
2 Star Discount
Annual Mileage
Driver Record Level Surcharge

During the past 5 years has any driver or household member had
����������� A major violation?������������������No
����������� License suspended, revoked, or refused?������������������No
Does any driver have
����������� An at-fault accident within the last� 3�years?������������������No
����������� A minor violation within the last� 3�years?������������������Yes
Primary use of vehicle?To/from work/school

Policy owners (Named insureds):Corpus, Benjamin
Effective date:03-10-2012
Policy number:757 6688-C10-35
Application date:03-10-2012
Application time:02:14:15 PM CST

A State Farm representative may contact you soon to arrange for inspection of your vehicle and to obtain the documents required below:

State Farm Fire and Casualty Company of Bloomington, Illinois , hereby binds as of the requested effective date for a period of 30 days from such date, the insurance applied for, subject to all of the terms and conditions of the automobile policy and applicable endorsements in current use by such Company. The issuance by the Company of the Declarations page of the policy applied for voids this binder.

Fraud Warning: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Consumer reports, including credit and insurance loss history reports, may be ordered in conjunction with this application. We may also obtain and use a credit-based insurance score developed from information contained in these reports. We may use a third party in connection with the development of your insurance score. These reports provide information that assists with determining your eligibility for insurance and the price you are charged. A brochure explaining how State Farm uses insurance scores is available upon your request.

By submission of this application, you agree that: (1) you have read this application, (2) your statements on this application are correct, (3) statements made on any other applications on this date for automobile insurance with this company are correct and are made part of this application, (4) you are the sole owner of the described vehicles except as otherwise stated, and (5) the limits and coverages were selected by you.  It is further understood and agreed that no insurance is effective under this agreement (A) unless the binder is completed designating the company accepting this application or (B) until the date the policy or binder is issued by the company accepting this application.

Policy owners (Named insureds):Corpus, Benjamin
Effective date:03-10-2012
Policy number:757 6688-C10-35
Application date:03-10-2012
Application time:02:14:15 PM CST

IB OH .5 (rev 08/2011)