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Neighbors Insurance Services, LLC
Limited Service Agreement
Neighbors Insurance Services, LLC. and the insurance producer listed at the end of this Agreement (collectively “Producer”) will provide to the undersigned (“You” and “Your”) the services set forth in Paragraph 1 below.
1. Services. Producer will provide You the limited services described below for the non-refundable and fully earned fees set forth on the attached schedule. The fees are not part of the policy premium and will not be billed by the insurance company.
X Customer Service: Producer will assist You in submitting an application for insurance on a policy purchased through Producer that provides the coverages requested below in Paragraph 2. Producer or another insurance producer with Neighbors Insurance will also assist You with changes to and payments on Your policy. You must secure a receipt for any payments made at Neighbors Insurance office as proof of Your payment. I also authorize Producer to order my credit report and obtain an insurance score for purposes of providing me a quote now or in the future.
State Financial Responsibility Filings: Producer will assist You in filing documents with the State to gain reinstatement or prevent suspension of Your license. You agree to follow up with the State to ensure that it was received and accepted all necessary documents (including those that Producer assists You in filing) and payments required to reinstate or prevent the suspension of Your license. See the release language in paragraph 4 below.
JCX Service: Producer will file an SR-22 and any other required documents with the State with expedited service. The same terms, conditions and limitations of the State Financial Responsibility Filings will apply.
_______ I DO NOT wish to have Neighbors Insurance file my reinstatement documents or pay my reinstatement fees to the state to have my license reinstated with the JCX Service. I understand that I must file any documents and pay any fees due before my license will be reinstated with the state. My initials indicate this rejection.
2. Coverages Requested.You request Producer to assist You in submitting an application for any of the coverages listed below and marked with an “X”:
X State Required Liability Coverages and Limits: $25,000 per person for bodily injury, $50,000 per accident for bodily injury and $10,000 per accident for property damage.
X State Required Uninsured Motorists Coverage: $25,000 per person for bodily injury, $50,000 per accident for bodily injury.
X State Required Personal Injury Protection Benefits (KS Only) (Only available if application for coverage reflects vehicle is garaged in Kansas)
_______ Nations Safe Driver Motor Club
_______ Increased Limits of Liability: Bodily Injury ______/______ Property Damage ________
Medical Payments Coverage: Limits____________________
Underinsured Motorists Coverage: Bodily Injury ______/______
Collision Coverage - Deductible: ____________
Other Than Collision (also known as Comprehensive) - Deductible: ____________
Special Equipment. Describe: _____________________________
Towing &/or Rental Reimbursement (Available through the insurance company providing Collision Coverage and Other Than Collision Coverage.
Non-owner Policy. This will include the state required liability coverages and limits unless the increased limits of liability coverage option is selected.
Business Use: Describe business:______________________________
**** You will not receive any coverages unless (i) it is marked with an “X”, (ii) You ensure that it is reflected on Your application for insurance, (iii) You pay an additional premium, and (iv) You verify such coverage is reflected on Your declarations page after it is delivered to You.
3. Disclosures: Prior to entering into this Agreement, we searched the insurance markets available to us to provide You with a quote. You did not pay us a fee to provide You that quote, but You will pay us to provide You the services requested in this Agreement. The quote we gave You may not be the lowest price among all the insurance companies available through us for which You qualify. We receive compensation from the insurance companies with whom we place business. This compensation is based on (i) the amount of Your premium, (ii) the number of policies and total amount of premium we place with the companies, and (iii) the number and amount of claims our customers make on policies purchased through us.
4. Release: The assistance we provide You in connection with satisfying Your financial responsibility requirements to the state is handled and processed by fallible human, electronic and other sources. The consequences that can result from state records failing to reflect that You have satisfied Your financial responsibility requirements can be severe and can include, but are not limited to: (i) the suspension of Your license, (ii) the imposition of fines and penalties, and (iii) incarceration in a jail or other holding facility. Due to the nominal amount of the fee we charge to assist You in satisfying Your financial responsibility requirements and the resulting serious consequences for failing to provide that assistance, Producer cannot assume any liability for such failure in excess of the fee charged even if it is through the fault of the Producer or other employees. By signing below, You agree to release the insurance company that issues Your policy, Producer, and all other employees, officers, directors and affiliated companies, from any liability related to or arising out of the services provided to You, including, but not limited to, assisting You in satisfying Your financial responsibility requirements..
This agreement is in furtherance of Section 375.116, RSMo and Mo Dept of Ins Reg 20 CSR 700-1.100 and KSA Section 40-4911.
Dated: ___/___/___ ___ __________
Customer Signature Print Customer Name
Neighbors Insurance Services, LLC
Dated: ___/___/___ By Linda Stites _________________________ License Number: ____PR286824______________
Producer Signature
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