Agreement to Provide Insurance

 

AGREEMENT TO PROVIDE INSURANCE

 

CUSTOMER NAME:_________________________________________________________________________

 

ADDRESS:_________________________________________________________________________________

 

CITY, STATE & ZIP CODE:___________________________________________________________________

 

YEAR/MAKE/MODEL:_______________________________________________________________________

 

VIN#:______________________________________________________________________________________

 

 


AGENT INFORMATION

 

NAME:___________________________

 

ADDRESS:________________________

 

__________________________________

 

PHONE #:_________________________

 

INSURANCE COMPANY INFORMATION

 

NAME:_______________________________

 

POLICY #:____________________________

 

EFF DATE:_________ EXP DATE________

 

DEDUCTIBLES: COMP______COLL______



LIEN HOLDER: MIDWEST ACCEPTANCE CORP

                          1257 DOUGHERTY FERRY RD
                          P.O. BOX 9
                          VALLEY PARK, MO  63088-0009

 

 

I(WE) UNDERSTAND THAT I(WE) MUST PROVIDE COMPREHENSIVE AND COLLISION INSURANCE WITH A MAXIMUM OF $500 DEDUCTIBLES ON THE VEHICLE DESCRIBED ABOVE AT ALL TIMES. IT IS ALSO UNDERSTOOD THAT FAILURE TO PROVIDE ACCEPTABLE INSURANCE COVERAGE CAN RESULT IN MIDWEST ACCEPTANCE CORP DEMANDING THE ENTIRE BALANCE DUE AND PAYABLE IMMEDIATELY.

 

 

SIGNED______________________________________________________________________

 

DATED_______________________________________________________________________