AB1142DPC-0514 AB1142DPC
Not Required
________________________________________________ _______________________________________________
Countersignature of Authorized Representative Certificate Holder’s Signature
(If signed electronically, your name will be printed)
____________
Date
CERTIFICATE NUMBE
R
American Bankers Insurance Company of Florida
A Stock Insurance Company
ADMINISTRATIVE OFFICE: 400 Carillon Pkwy, Ste 300, St. Petersburg, FL 33716
USAA EXTENDED VEHICLE PROTECTION
MECHANICAL BREAKDOWN INSURANCE
CERTIFICATE DECLARATIONS
CERTIFICATE HOLDER INFORMATION VEHICLE INFORMATION
LAST NAME FIRST NAME MI YEAR MAKE MODEL
ADDRESS EMAIL ODOMETER READING IN-SERVICE DATE VEHICLE PURCHASE PRICE
CITY/STATE/ZIP CODE TELEPHONE NUMBER VIN
COVERAGE INFORMATION
VEHICLE CLASSIFICATION CERTIFICATE TERM COVERAGE LEVEL
NEW PRE-OWNED MONTHS MILES
DEDUCTIBLE TOTAL PREMIUM
Agreement Price: Sales Tax: Total:
PURCHASE DATE EXPIRATION DATE EXPIRATION MILEAGE METHOD OF PAYMENT
CREDIT CARD CASH/CHECK
FINANCED INSTALLMENTS
GROUP POLICY HOLDER INFORMATION
NAME TELEPHONE NUMBER
USAA Federal Savings Bank 800-531-8722
ADDRESS CITY STATE ZIP CODE
10750 McDermott Freeway San Antonio TX 78288
ENDORSEMENTS
T
he following Endorsements attached to and form part of this Certificate:
AB1153EPC-0514
CERTIFICATE HOLDER NOTICE
T
he Certificate Holder must provide all of the information requested in this Certificate Declarations in order to validate the Certificate.
This Certificate Declarations shall be the basis upon which the Certificate is issued. The Certificate Holder’s (a) verbal authorization to
our telephone agent and subsequent receipt of your Certificate and Schedule of Coverage or (b) The Certificate Holder’s electronic
signature (by accepting the Privacy Statement electronically) confirms our right to charge the price quoted and indicates that the information
the Certificate Holder has provided is true and correct, and also that the Certificate Holder accepts the terms and provisions of this
Certificate as they have been described and the Certificate Holder agrees to be bound by the terms thereof. This document takes
precedence over any oral or written statements given to the Certificate Holder. Once the Certificate Holder receives the Certificate and
Schedule of Coverage if the Certificate Holder wishes to cancel the Certificate Holder has sixty (60) days to notify the Company (as
described in the Cancellation section) and receive a full refund.
I understand that I may return the Certificate within sixty (60) days for any reason and receive a full refund. To review the General Privacy
Policy of American Bankers Insurance Company, an Assurant Solutions company, please visit http://www.assurantsolutions.com/pri-privacy-
notice-t4.html.
SAMPLE
