| dan Philadelphia, PA 83814 |
<table width="100%" style="padding-top: 10px;" ><tr><td style="width: 33%; font-size: 9pt; font-weight: bold;">First Name</td><td style="width: 33%; font-size: 9pt; font-weight: bold;">LastName</td><td style="width: 33%; font-size: 9pt; font-weight: bold;">Application Id</td></tr><tr><td style="width: 33%;">dan</td><td style="width: 33%;">**********</td><td style="width: 33%;">A00000002128</td></tr><tr><td width="100%; font-size: 9pt; font-weight: bold; padding-top: 10px;" colspan="3">Address</td></tr><tr><td width="100%;" colspan="3">********** Philadelphia, PA 83814</td></tr><tr><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px;">Phone</td><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px;">Email</td><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px;">Gender</td></tr><tr><td style="width: 33%;">***********</td><td style="width: 33%;">**********</td><td style="width: 33%;">MALE</td></tr><tr><td width="100%;" colspan="3" style="padding-top: 10px; font-size: 10pt; font-weight: bold;">Drivers<hr/></td></tr><tr><td style="width: 33%; font-size: 9pt; font-weight: bold;">Name</td><td style="width: 33%; font-size: 9pt; font-weight: bold;">Date of Birth</td><td style="width: 33%; font-size: 9pt; font-weight: bold;">Marital Status</td></tr><tr><td style="width: 33%;"></td><td style="width: 33%;">12/15/1987</td><td style="width: 33%;">Domestic Partner</td></tr><tr><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px; ">Occupation</td><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px; ">License Status</td><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px; ">Relationship</td></tr><tr><td style="width: 33%;">Attorney3</td><td style="width: 33%;">Temporary</td><td style="width: 33%;">Applicant</td></tr><tr><td width="100%;" colspan="3" style="padding-top: 10px; font-size: 10pt; font-weight: bold;">Vehicles<hr/></td></tr><tr><td style="width: 33%; font-size: 9pt; font-weight: bold;">Make</td><td style="width: 33%; font-size: 9pt; font-weight: bold;">Model</td><td style="width: 33%; font-size: 9pt; font-weight: bold;">Trim</td></tr><tr><td style="width: 33%;">KOENIGSEGG</td><td style="width: 33%;">Agera</td><td style="width: 33%;">Passenger Car</td></tr><tr><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px; ">Ownership</td><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px; ">Usage</td><td style="width: 33%; font-size: 9pt; font-weight: bold; padding-top: 10px; ">Annual Miles</td></tr><tr><td style="width: 33%;">Leased</td><td style="width: 33%;">Business</td><td style="width: 33%;">0</td></tr><tr><td width="100%;" colspan="3" style="padding-top: 10px; font-size: 10pt; font-weight: bold;">Coverages</td></tr><tr><td style="width: 33%; font-size: 9pt; font-weight: bold;">Comprehensive</td><td style="width: 33%; font-size: 9pt; font-weight: bold;"> </td><td style="width: 33%; font-size: 9pt; font-weight: bold;">Deductible: $250 ACC</td></tr><tr><td style="width: 33%; font-size: 9pt; font-weight: bold;">Collision</td><td style="width: 33%; font-size: 9pt; font-weight: bold;"> </td><td style="width: 33%; font-size: 9pt; font-weight: bold;">Deductible: $250 ACC</td></tr><tr><td width="100%;" colspan="3" style="padding-bottom: 20px;"><hr/></td></tr></table> |
