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Applicant's Statement

Applicant’s Statement:

I apply to the Occidental Fire & Casualty Company of North Carolina (“Occidental”) for a policy of insurance based upon the information I have supplied and the statements I have made herein. I agree that if such information is false, misleading, or would materially affect acceptance of the risk by Occidental, or if the payment for this policy made by me or on my behalf (except by the agent or broker), is not honored by the payer (bank), coverage may be cancelled.

I understand that if my premium check, intended to be the down payment or full repayment, is returned unpaid by the bank, the policy will be null and void, with appropriate notification, and I will be subject to applicable fees.

If information developed by Occidental indicates there should be a different classification or premium than indicated above, I authorize Occidental to endorse or issue the policy to reflect the proper rate(s) and terms.

I declare that all the statements contained in this application are complete and true to the best of my knowledge as to this date. I understand that the company may exchange payment of premium information and accident or claim information with my previous automobile insurance company.



False Information

I am aware that under the terms of my Massachusetts Automobile Insurance Policy, if I, or someone on my behalf, provides false, deceptive, misleading or incomplete information in any application or policy change request, and if such false, deceptive, misleading or incomplete information increases the company’s risk of loss, the company may refuse to pay claims under any or all of the Optional Insurance Parts of this policy. Such information includes the description and the place of garaging or parking of the vehicles to be insured, the names of all household members and customary operators required to be listed and then answers given for all listed operators. Payments under Compulsory Insurance Parts may also be limited to those amounts that the company is required to sell.

In addition, I am aware Massachusetts law requires that the company withhold payment of a Collision or Limited Collision loss if the insured auto is being operated by a household member who is not listed as an operator on my policy. Payment is withheld when the household member, if listed, would require the payment of additional premium on my policy because the household member would be classified as an inexperienced operator or would require payment of additional premium on my policy under the Merit Rating Plan.







Motor Vehicle Registration Requirements

You are responsible for any and all motor vehicle registration requirements. If you should have any questions regarding registering your motor vehicle, please contact A-Affordable.



Underwriting Company Information

Motor vehicle insurance policies are underwritten by::

Occidental Fire and Casualty Company of North Carolina

702 Oberlin Road

Raleigh, North Carolina 27605-1102

Payment Authorization and Information

I authorize Occidental Fire & Casualty Company of North Carolina and/or its assigns to use Electronic Funds Transfer, a bank draft, or my credit/debit card for an insurance premium payment across the internet.

If another form of payment is utilized, coverage will not be effective until that payment is cleared.

Appointing A-Affordable as Broker

By purchasing automobile insurance through the A-Affordable web site, you appoint A-Affordable as your broker. Further, after selecting your automobile insurance, you authorize A-Affordable to place the coverage you selected.

Coverage may not be effective until the proper deposit is paid. A-Affordable will process your application efficiently but it is also important to note that coverage will not be effective immediately following the completion of the application. Additionally, there may be delays beyond A-Affordable’s control and A-Affordable cannot be held responsible for those delays.

Payment Terms

By utilizing the A-Affordable web site you also agree to the following payment terms:

  • You promise to pay the amount shown when due as indicated in the contract you complete at the time of purchase.

  • The unpaid balance may be paid in full at any time.

  • If you are in payment default, the underwriting insurance company may demand full payment or cancel the policy.

  • You may be charged a delinquency charge of $10.00 if your payment is postmarked/uploaded 6 or more days after the installment due date.

  • You will be charged a billing installment service fee equal to $10.00

  • You will be charged a fee of $25.00 to reinstate a cancelled policy.

  • You will be charged a processing fee of $15.00 for insufficient funds when checks are denied by financial institution.

  • You will be charged a policy fee of $25.00 for new and renewal policy terms.

  • If a payment default is waived, this has no effect on future payment defaults.

Cancellation of Policy

We reserve the right to cancel your policy for non-payment of premium. The cancellation will be in accordance with Massachusetts General Laws. You will receive a cancellation notice and you will have until the date that the cancellation is to take effect in which to pay the premium and avoid cancellation.

Last Updated: 4/15/15