IMPORTANT NOTICE REGARDING

"Big enough for all your insurance needs. Small enough to know your name."

PERSONAL AUTOMOBILE INSURANCE

WAITING PERIODS

To our Valued Customers:

The New Jersey Administrative Code approved and supported by the Department of Banking and Insurance allows insurers to impose a “10 business day waiting period” before binding coverage on a completed written application for Personal Automobile Insurance.

While this legal action may result in a lapse in your coverage, we urge you to make other arrangements during your “uninsured” period for your transportation and DO NOT DRIVE ANY UNINSURED VEHICLE.

Severe legal penalties apply if you are cited for driving while uninsured, which will further add to the cost of your future automobile insurance premiums.

The Norwood Agency, Inc. will in no way be held responsible for losses or penalties suffered by you during any uninsured time period.

We will continue to strive to provide the best coverage and service to you, our valued customer, and will keep you apprised of any further insurance industry changes.

Thank you for your understanding.

THE NORWOOD AGENCY, INC.

LEASE RETURN TO THE LOCATION NEAREST YOU!

AUTOMOBILE INSURANCE – MANDATORY DOCUMENTATION

At time of application for automobile insurance, the following documentation must be presented in order to bind coverage:

1. Copies of NJ driver’s licenses for all licensed drivers in the household.

2. Copies of all registrations/titles for vehicles to be insured.

3. Copies of auto lease agreements, if applicable.

4. Proof of Residency: utility bill, bank statement, credit card bill,

or other such evidence that clearly indicates the applicants name

and address and is dated within the past 30 days.

5. Evidence of last 12 months of insurance (ID cards, dec. page).

6. Evidence of insurance for all other drivers in household.

7. Deposit premium to be determined at time of quote.

8. Please note that other documents may be requested due to individual circumstances.

APPLICATIONS ARE DONE BY APPOINTMENT ONLY

PLEASE NOTE THAT WE WILL NOT BE ABLE TO COMPLETE YOUR APPLICATION

IF ANY OF THE ABOVE INFORMATION IS NOT FURNISHED. THERE ARE NO EXCEPTIONS.

PLEASE BE SURE TO HAVE ALL MANDATORY DOCUMENTS AVAILABLE

IN ORDER TO PREVENT A DELAY IN OBTAINING COVERAGE.

Automobile Insurance Worksheet

Name:

Street:

City: State: Zip:

PRIOR ADDRESS IF NOT AT ABOVE ADDRESS FOR 3 YEARS:

Street:

City: State: Zip:

PHONE #:

WORK#:

CELL #:

VEHICLE INFORMATION:

!.) YEAR: MAKE: MODEL:

DATE PURCHASED: VIN:

PRIMARY DRIVER #:

PASSIVE RESTRAINT: Yes No

ABS: Yes No

ALARM SYSTEM:Yes No

TAKEN TO WORK: Yes No IF YES, ONE-WAY MILEAGE: Miles

# DAYS TAKEN TO WORK:

ANNUAL MILEAGE:

2.) YEAR: MAKE: MODEL:

DATE PURCHASED: VIN:

PRIMARY DRIVER #:

PASSIVE RESTRAINT: Yes No

ABS: Yes No

ALARM SYSTEM:Yes No

TAKEN TO WORK: Yes No IF YES, ONE-WAY MILEAGE: Miles

# DAYS TAKEN TO WORK:

ANNUAL MILEAGE:

3.) YEAR: MAKE: MODEL:

DATE PURCHASED: VIN:

PRIMARY DRIVER #:

PASSIVE RESTRAINT: Yes No

ABS: Yes No

ALARM SYSTEM:Yes No

TAKEN TO WORK: Yes No IF YES, ONE-WAY MILEAGE: Miles

# DAYS TAKEN TO WORK:

ANNUAL MILEAGE:

Please list additional information below:

COVERAGE LIMITS:

LIABILITY LIMIT: THRESHOLD:

COMPREHENSIVE ON VEHICLE #:

DEDUCTIBLE: $

COLLISION ON VEHICLE #:

DEDUCTIBLE: $

LAST INSURANCE COMPANY NAME:

POLICY NUMBER:

EXPIRATION/CANCELLATION DATE:

YEARS OF CONTINUOUS COVERAGE:

REASON FOR CANCELLATION/NON-RENEWAL:

DRIVER INFORMATION:

1) NAME: DATE OF BIRTH:

DRIVER’S LICENSE/PERMIT #:

OCCUPATION:

DATE LICENSED: SOCIAL SECURITY #:

2) NAME: DATE OF BIRTH:

DRIVER’S LICENSE/PERMIT #:

OCCUPATION:

DATE LICENSED: SOCIAL SECURITY #:

3) NAME: DATE OF BIRTH:

DRIVER’S LICENSE/PERMIT #:

OCCUPATION:

DATE LICENSED: SOCIAL SECURITY #:

4) NAME: DATE OF BIRTH:

DRIVER’S LICENSE/PERMIT #:

OCCUPATION:

DATE LICENSED: SOCIAL SECURITY #:

Please list additional information below:

LOSS HISTORY:

LIST ALL ACCIDENTS/VIOLATIONS/CLAIMS FOR EACH DRIVER/VEHICLE FOR THE PAST FIVE YEARS:

ADDITIONAL INFORMATION:

THE NORWOOD AGENCY, INC.

NORWOOD LIFE ASSOCIATES, INC.

THE BLAISDELL AGENCY

FRANK D. FISH AGENCY, INC.

505 BROADWAY · LONG BRANCH, NJ 07740

PHONE: 732-222-2400

FAX: 732-222-7236

645 FISCHER BOULEVARD · TOMS RIVER, NJ 08753

PHONE: 732-270-0220

FAX: 732-929-1233

Visit us on our website @ www.norwoodagency.com

July 1, 2003

RE: OUR PRIVACY POLICY AND PRACTICES

Dear Valued Customer:

Our commitment to you is to provide superior service with personal attention and have been doing so for over 72 years. It is important for you to know that in order for us to provide you with the very best service and the highest quality products that we must collect information from you.

Your application is our major source of information. However, in order to evaluate your application for insurance and to service your policies, we may ask for other additional nonpublic personal information about you and any other person you wish to be insured under your policies.

Unless you tell us not to, this information may be shared with our affiliated companies and others, as permitted by law. We restrict access to nonpublic personal information about you to those employees who need to know that information in order to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

If you have any questions about our information practices, please contact us.