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# ALLSTATE INDEMNITY COMPANY #

MARYLAND
HOME OFFICE Application No.: 076211595255885
NORTHBROOK, ILLINOIS Policy Number: 808247962
Send Policy to Agent: N
Applicant Name : HASSANE BARRY
Address : 205 BISHOP AVE
City : BROOKLYN St: MD Zip: 21225
Telephone Num. : (240) 491-1314 County: 003 Terr.: 2401225
VEHICLES Own/
No Yr Make Description Vehicle ID Number Cy Dr CT PGS VSC Cost Lease
1 2013 FORD FOCUS FOCUS 1FADP3F25DL270200 4 4 10 P C41 Y/N
USE RATE
Odom Car Miles Date Est Ann Incl Rare Split Alt Table Weeks
No Usage One Way Purch Mi Cmpr Rest Terr Yr Rented
1: 80,837 PLEASURE 01/2013 10,000 N N 1225 00

2013 2013
FORD FOCUS FORD FOCUS
COVERAGES LIMITS Base Premium* Per-Mile Rate***
AA Bodily Injury Ea Per $100,000 $298.29 $0.097
Liability Ea Acc $300,000 Included Included
___________________________________________________________________________________

BB Prop Damage Ea Acc $100,000 $34.77 $0.047

Liability
___________________________________________________________________________________

SS Uninsured Mot Ea Per $100,000 $58.56 $0.000

Bodily Injury Ea Acc $300,000 Included Included
___________________________________________________________________________________

Prop Damage Ea Occ $50,000 Included Included

___________________________________________________________________________________

JJ Roadside $100 $7.32 $0.000

Coverage (Occ)
___________________________________________________________________________________

VA (Personal Injury Ded 01 $12.81 $0.018

Coverage) PIP
Plan(Plus
Optional
Deductible)
___________________________________________________________________________________

Approximate Total
Estimated Vehicle Premiums Base Premium* Per-Mile Rate****
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# ALLSTATE INDEMNITY COMPANY #

MARYLAND
HOME OFFICE Application No.: 076211595255885
NORTHBROOK, ILLINOIS Policy Number: 808247962
2013 FORD FOCUS $411.75 $0.162
___________________________________________________________________________________

*Base Premium is based on a Daily Rate multiplied by the number of days in the
Policy Period.
___________________________________________________________________________________
***Total mileage premium is based on the Per-Mile Rate times the number of miles
driven subjected to rounding in accordance with the rules, rates, and forms in
effect and on file in your state. Chargeable miles are capped daily.

****The Approximate Total Per-Mile Rate is calculated based on the rates per mile
for the coverages selected for each vehicle. See the Coverages section for the
actual Per-Mile Rate for each coverage selected. Rounding may occur in the
calculation of the Approximate Total Per-Mile Rate.

___________________________________________________________________________________

POLICY COVERAGE LIMITS POLICY

PREMIUM
___________________________________________________________________________________

CM Death Indemnity $10,000 Included

___________________________________________________________________________________

Estimated Policy Coverages Premium $0.00

___________________________________________________________________________________

Your Estimated Vehicle Premium Reflects the Allstate Standard Package

Summary of Discounts -Your total premium includes the following discounts:

Safe Driving Club® 1 qualified driver(s)
Multiple Policy
Smart Student 1 qualified driver(s)
The following discount(s) apply to Vehicle #1: 2013 FORD FOCUS
Antilock Brake
Passive Restraint
Electronic Stability Control

Total Base Premium: $411.75

Total Premium is the Base Premium of $411.75 plus mileage premium.

Premiums charged must be in accordance with the Company's manual rules and rates
Amount Paid: 161.00 Credit Card
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# ALLSTATE INDEMNITY COMPANY #

MARYLAND
HOME OFFICE Application No.: 076211595255885
NORTHBROOK, ILLINOIS Policy Number: 808247962
___________________________________________________________________________________
HOUSEHOLD SECTION (APPLIES TO APPLICANT ONLY)
Mo Yr at Present Residence: 06/2016 Residence Type: AP Own or Rent: RE
Years at Present Employment: 10 Other Vehicles Owned in Household: N
Is this the address where the vehicles are principally garaged? Y
___________________________________________________________________________________
INSURANCE RECORD (PRESENT OR MOST RECENT AUTO INSURANCE CARRIED)
Prior Co: GEICO GEN INS Policy Number: 4197835947
Exp Date: 12/14/2021 Years/Months Insured: 10/11 PI Code: OT
Is the above policy JUA or Assigned Risk? N

Current Allstate Pol: Y Pol No: 076211595255887 Eff:06/08 Line:71 Rel:MT

___________________________________________________________________________________

OPERATOR INFORMATION ON ALL DRIVING MEMBERS OF HOUSEHOLD

Name: HASSANE BARRY Sex: M DOB: 08/XX/1965
Relation to Ins: SA INSURED Occupation: EM NA Mar St: SI
Orig Date Licensed: 08/1981 Drivers Lic
No: XXXXXXXXX1603
State Lic: MD DD Course Completion Date:
SS No: XXX/XX/0484
Accident/Violation History
DT: 20210109 Desc: Misc. (Multiple car accident) Fault: Y Concurnt: N
Name: ANDOULAYE BARRY Sex: M DOB: 09/XX/2002
Relation to Ins: CH CHILD/PARENT Occupation: EM NA Mar St: SI
Orig Date Licensed: 09/2018 Drivers Lic
No: XXXXXXXXX4724
State Lic: MD DD Course Completion Date:

___________________________________________________________________________________
REMARKS:

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# ALLSTATE INDEMNITY COMPANY #

MARYLAND
HOME OFFICE Application No.: 076211595255885
NORTHBROOK, ILLINOIS Policy Number: 808247962
___________________________________________________________________________________
BINDER PROVISION
Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false
information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
In reliance on the statements in this application and subject to the terms and
conditions of the policy authorized for the Company's issuance to the applicant,
the Company named above binds the insurance applied for to
Become Effective 10:12 AM 06/08/2021
In reliance on the statements in this application and subject to the terms and
conditions of the policy authorized for the company's use, the company named
above, binds for a period of 30 days the insurance applied for. However, the
company may sooner terminate the insurance by mailing written notice of rejection
to the applicant. The insurance applied for is to become effective on the date
shown above.
Application Signed 10:12 AM 06/08/2021

________________________
AMY SALMON No: 0B8495
Agent/Agency Name
___________________________________________________________________________________
To the best of my knowledge the statements made on these application pages,
including attachments hereto, are true. I certify that the information concerning
insurance history, auto usage, and drivers used to compute my premium is correct
and that I am eligible for the appropriate discounts indicated above. I request
the company in reliance thereon, to issue the insurance applied for. I understand
that my premium may be increased due to re-tiering or loss of discounts if
supporting documents requested by the company are not returned by me. I declare
that the Company may cancel the policy, or recalculate the premium from the
effective date, if the statements made herein are not substantially true,
information is incorrectly recorded, or the Company discovers that I failed to
disclose material information.
Many factors go into the cost of your auto insurance policy, including how you
purchase the policy. Your price will vary depending on whether you buy online,
through a call center, or through an agent because of differences in costs for
sales, service and marketing.
I have read this entire application, including the binder provision,
before signing.
Signed by: HASSANE BARRY
Date: 2021.06.08 09:25:16 CDT
____________________________________ _____________________
APPLICANT'S SIGNATURE DATE
___________________________________________________________________________________
NOTICE: As part of Allstate's underwriting/qualification procedure and subject to
applicable laws and regulations, we may obtain information regarding you and
other individuals who may be covered by the insurance you are applying for,
including: (i) driving record, based on state motor vehicle reports and loss
information reports; (ii) your prior insurance record, if any, which will be

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# ALLSTATE INDEMNITY COMPANY #

MARYLAND
HOME OFFICE Application No.: 076211595255885
NORTHBROOK, ILLINOIS Policy Number: 808247962
obtained from your current or prior carrier(s); (iii) credit reports; and (iv)
claim history, based on loss information reports.
You may request a premium quotation that separately identifies the portion of
premium applicable to credit history. We will review the credit history of an
insured who was adversely impacted by the use of credit history at initial rating
of the policy every two years or on the request of the insured. You may request
us to review your credit history once per policy period, and if your credit
history has improved, any adjustment of premium will take effect at the next
renewal following our review of credit history.
___________________________________________________________________________________
If your payment of the initial premium amount due is by check, draft, or any
remittance other than cash, such payment is conditional upon the check, draft, or
other remittance being honored upon presentation. If such check, draft, or
remittance is not honored upon presentation, this Binder (and any policy
delivered to you pursuant to this application) shall be deemed void from its
inception. This means that Allstate will not be liable for any claims or damages
which would otherwise be covered had the check, draft, or remittance been honored
upon presentation.
___________________________________________________________________________________

APP150-1

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