STANDARD BROKER FEE DISCLOSURE This disclosure was prepared by the California Insurance Commissioner. Please READ IT CAREFULLY! I. Do not sign any broker fee agreement unless all of its blank lines and spaces have been filled-in and you have read the entire document and the agreement carefully. II. Your insurance broker represents you, the consumer, and is entitled to charge a broker fee if he/she chooses. This fee is not set by law, and may be negotiable between you and the broker. III. It is illegal for an insurance broker to charge you a fee for placing coverage solely with the California Automobile Assigned Risk Plan or the California Fair Plan. Fees may be charged for placement of other overages. IV. Broker fees are often non-refundable even if you cancel your coverage. Refer to your broker fee agreement to see if your broker fee is non-refundable. However, you may be entitled to a full refund of a broker fee if your broker acted incompetently or dishonestly. Unresolved disputes over non- refundable broker fees can be forwarded to the Department of Insurance for review. V. You are entitled to obtain and keep a completed copy of this disclosure and any broker fee agreement you sign. VI. Your broker may receive a commission from insurance company (ies) for placing your insurance. this commission may be paid to your broker by the insurance company (ies) in addition to any broker fee you pay. VII. If you will be paying your premium in installments to a finance company, by law you must receive a copy of a premium finance disclosure and agreement. Be sure to obtain and read those documents before signing a premium finance agreement. Also, ask the broker if the insurer offers its own installment payment plan. Insurer installment plans are often cheaper than premium financing through a separate premium finance company. VIII. If your broker is placing automobile coverage, your broker must provide you with a copy of the current Department of Insurance pamphlet Automobile Insurance. If your broker is placing residential coverage, your broker must provide you with a copy of the current Department of Insurance pamphlet Residential Insurance. By signing this disclosure, you acknowledge receipt of the appropriate pamphlet(s). Client Initials: ____________ EARN $50 IN CASH OR CREDIT TOWARD YOUR MONTHLY PAYMENT WHEN YOU REFER A FRIEND OR FAMILY MEMBER. JUST MENTION COUPON CODE # 50REF AND YOUR NAME Cash reward apply for new Policy only. Other restrictions apply. NEW MILLENNIUM INSURANCE 714-530-1234 jm jm
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STANDARD BROKER FEE DISCLOSURE
This disclosure was prepared by the California Insurance Commissioner. Please READ IT
CAREFULLY!
I. Do not sign any broker fee agreement unless all of its blank lines and spaces have been filled-in and
you have read the entire document and the agreement carefully.
II. Your insurance broker represents you, the consumer, and is entitled to charge a broker fee if he/she
chooses. This fee is not set by law, and may be negotiable between you and the broker.
III. It is illegal for an insurance broker to charge you a fee for placing coverage solely with the California
Automobile Assigned Risk Plan or the California Fair Plan. Fees may be charged for placement of
other overages.
IV. Broker fees are often non-refundable even if you cancel your coverage. Refer to your broker fee
agreement to see if your broker fee is non-refundable. However, you may be entitled to a full refund of
a broker fee if your broker acted incompetently or dishonestly. Unresolved disputes over non-
refundable broker fees can be forwarded to the Department of Insurance for review.
V. You are entitled to obtain and keep a completed copy of this disclosure and any broker fee agreement
you sign.
VI. Your broker may receive a commission from insurance company (ies) for placing your insurance. this
commission may be paid to your broker by the insurance company (ies) in addition to any broker fee
you pay.
VII. If you will be paying your premium in installments to a finance company, by law you must receive a
copy of a premium finance disclosure and agreement. Be sure to obtain and read those documents
before signing a premium finance agreement. Also, ask the broker if the insurer offers its own
installment payment plan. Insurer installment plans are often cheaper than premium financing through a
separate premium finance company.
VIII. If your broker is placing automobile coverage, your broker must provide you with a copy of the current
Department of Insurance pamphlet Automobile Insurance. If your broker is placing residential
coverage, your broker must provide you with a copy of the current Department of Insurance pamphlet
Residential Insurance. By signing this disclosure, you acknowledge receipt of the appropriate
pamphlet(s).
Client Initials: ____________
EARN $50 IN CASH OR CREDIT TOWARD YOUR MONTHLY PAYMENT
WHEN YOU REFER A FRIEND OR FAMILY MEMBER. JUST MENTION COUPON CODE # 50REF AND YOUR NAME
Cash reward apply for new Policy only. Other restrictions apply.
MNS3348370*124*Page 1 of 10AU APP 07/08 – Copyright
Alliance United Insurance Company
MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ
RECORD MAINTENANCE AMENDMENT - FILE DOCUMENTS
MNS3348370
JASON ANSURIO MAGALLANESSANCHEZ
POLICY #:
INSURED NAME:
5/18/2015 12:05 PM PT
DATE:
L & K Millennium Insurance Inc
BROKER NAME:
BROKER CODE:13018
License No: 0C17987
The documents listed in this form must remain in the policyholder’s file and be maintained by your brokerage for a minimum of five (5) years
from the expiration/cancellation date of this policy.
Please place this form in the file and confirm the documents are included by checking the appropriate box. It is the responsibility of the
producing broker to complete this form and maintain all records in accordance with the Alliance United Record Maintenance Amendment.
A fully and completed signed application including Uninsured Motorist Waiver¨Copy of MVR’s for all listed drivers (unless Alliance United's on-line MVR is used when bridging the application)¨
Copies of Driver’s license or I.D. for all drivers domestic or foreign.¨
Copies of the current registration or sales contract (new or used vehicles) for all vehicles.¨Photos
Will be waived for new and used vehicles that are purchased or leased from a dealer within the last 30 days. A copy of the
sales contract for each vehicle must accompany the application.
Will be required and retained for all vehicles rated as artisan regardless of coverages.
Brokers are responsible for taking two photos showing all sides of the vehicle. The photos must be retained with the application.
¨
Will be waived if a copy of the prior policy is in the file showing Physical Damage coverage for the vehicle(s) with no lapse in
coverage.
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Proof of No-Fault or No-Bodily Injury Accident (if applicable).¨
Signed Driver Exclusion (If applicable).
Proof of Marriage / Proof of identification of an excluded spouse / domestic partner ¨
Proof of identification will be required for the excluded spouse when the system asks for proof at time of upload. We will
require proof the excluded spouse exists and resides with the insured if the registration or other file documents show both
names. Examples of proof are: a photo ID, a bill in the excluded persons name showing the same address as the insured,
a marriage certificate or tax return.
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Registered Owners are listed as a driver or excluded.¨
Copy of the FSC or other rating service quote.¨
Marriage rates apply to domestic partners living in the same household. Domestic Partnership Affidavit is acceptable only
for same sex partners. Same requirements for proof as above.
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THIS COVER PAGE, APPLICATION AND REQUIRED BACKUP ARE FOR ELECTRONIC PURPOSES ONLY.
**** IMPORTANT NOTICE ****
ANY REQUESTS FOR CHANGES, MODIFICATIONS OR AMENDMENTS MUST BE SUBMITTED TO ALLIANCE UNITED SEPARATELY BY
FAX (866) 530-2500 OR E-MAILED TO [email protected] IN ORDER TO BE ACKNOWLEDGED FOR PROCESSING
AND BINDING OF COVERAGE.
MNS3348370*124*Page 2 of 10AU APP 07/08 – Copyright
Alliance United Insurance Company
MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ
Broker Policy #
Broker Name and Address
13018
L & K Millennium Insurance Inc
12801 Harbor Blvd Suite H-5
GARDEN GROVE, CA 92840
(714) 530-1234
MNS3348370NAIC No.
10920
Millennium
Program Name
Applicant Information
Named Insured Mailing Address Effective Date & Time Expiration Date & Time Payment Plan