TO LESSOR CULA, LLC. 9665 Granite Ridge Dr. Ste 400 San Diego, CA 92123
The undersigned Lessee(s) agree(s) to furnish an insurance certificate covering the vehicle which is the subject of a Lease Agreement dated this day of
.
The vehicle referred to herein is described as follows:
Year
Make
Model
Body
Identification Number
Such insurance certificate must be delivered, as indicated below, within 30
days from the date hereof and indicate maintenance of insurance described below.
If Lessor does not receive such certificate, or other satisfactory evidence of
coverage, it may exercise its default remedies under the lease.
Ins. Co
Agent
Address of Agent – Street
City
State
Zip
Agents Phone Number
Policy No.
Exp. Date
By my signature below, I authorize the following changes / additions to accommodate my automobile lease,and I agree to provide a copy to my insurance agent.
Requirements unless the vehicle is garaged in a state which has minimum requirements:
$100,000 Bodily Injury Per Person
$300,000 Bodily Injury Per Accident
$50,000 Property Damage
$1,500 Maximum Deductible Comprehensive
$1,500 Maximum Deductible Collision
CONSUMER LEASE ONLY While the
vehicle is garaged in a state, which has minimum requirements, my liability
insurance only needs to satisfy the state mandated minimum liability limits.
Signed
Customer Name
Customer Address
Home Phone
Business or Cell Phone
Co-Lessee
must be listed as Loss Payee
FINANCIAL INSTITUTION NAME
and
CULA, LLC. must be listed as Additional Insured,
Certificate of insurance showing both designations is to be mailed to:
INSURANCE SERVICE CENTER P.O. BOX 5975 TIMONIUM, MD. 21094-6093
PHONE: (800) 695-8419 FAX: (267) 295-6099
Insurance Verified By (Signature Required)
My signature indicates I have verified the
lessee has at least the state required minimum liability insurance limits on
the vehicle identified above.
