Passenger Application

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2. Driver and Beneficiary Information

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Beneficiary Name
Indicate Type of Driver
including an authorized passenger
Paid by:
Annual Plan:
Accept Supplemental Accident Benefits ($24.00/year)
I accept or reject
The Passenger Accident insurance offered by the above listed Policyholder or Participating Motor Carrier. I understand that coverage becomes effective when this application has been received and approved by Great American Insurance Company or its authorized agent. I further understand that coverage terminates on the date the policy is terminated; or I am no longer under contract with the above mentioned motor carrier; or my premium is not paid. I also understand that coverage may be available on an individual policy subject to underwriting guidelines in effect at termination of the above policy.
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Medical Information Authorization: I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or any other organization, institution or person that has any records, including any medical history for the above named person to furnish such information or copies of records to the insurance companies association or its representatives. A photographic copy of this authorization shall be as valued as the original.
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FLORIDA STATUTE 817.234(1)(b) "Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree." NEW MEXICO STATUTE 59A-16C-8 "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties." OHIO INSURANCE CODE 3999.21 "Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insured, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud."