HomeMy WebLinkAboutDavid Meisner4WWestern Community
Insurance Company
PO Box 4848 Pocatello ID 83205-4848
Policyholder Information
Commercial Package
Service
EfftiDt
PolicyEffective Date:
05/15/2024
: 51825 P aecFn�n fit'
ID2f11 PWFi L t.• ry f'} Fq,e
Policy Expiration Date:
Policy Number:
Named Insured:
MEISNER DAVID
'� 9• +Q
2nd Name:
Mailing Address:
2978 S Bay Star Way
Address 2:
City, State, Zip:
Meridian, ID, 83642-3094
County Number: 01
County:
Ada
Email: dbmeisner@gmail.com
Primary Phone:
(208)954-0292
Sec Phone:
Entity Name:
Desc of Business: Hangar
DBA:
Agent Name:
Gardner, Jason B
Agent Number: 771
Signatory:
Meisner, David
Birth Date: 1971-02-03 SSN: 519-88-7096
Agent's Statement
have personally examined the property to be insured and cart fy that it is as represented and I have asked the applicant a)l quest ons pertaining to th s
applicat on and recorded the responses as of this date. In rel ante on the stalments to this applrcaton and subject to the terms and conditions of the
policy authorized for the company's issuance to the applicant the comparrvy named above binds the insurance applied for to become effective:
MVR Yes No 05/15/2024 M'
CBR Yes No Date Time
Application signed by Agent: PM
Dale Time Agent's Signature
On behalf of all applicants, i authorize the Company now and at any future time. to make routine inquiry of others concerning my/our mode of living,
financial condition, credit history, credit worthiness_ claims history. and who are residents of myrour household and their driver and vehicle histories. I
understand this information may be obta ned from a goverrmental agency. consumer credit agency or similar information provider.
agree that if my payment for premium under this policy is overdue, I will be responsible for any collection fees. court costs, or attorney fees incurred by
the Company. A S20.00 returned check fee w'.11 be assessed for any check or electronic fund transfer (EFT) that is returned unpaid to the Company.
am applying for a policy of insurance based on the informat on I have provided in this application. I declare that such information is true and correct.
understand that if I have Intentionally concealed or misrepresented any material fact or c rcumslance related to this nsurance, the terms of this pol cy
may be affected and there may be no coverage for an otherwise covered loss. 1 also understand that if the init al remittance for this insurance is not
honored by the bank such policy may be rescinded and considered void. I understand that the Company reserves the right to change rates or refuse
coverage on this application. I authorize the Company to endorse or issue the policy with the proper rate(s) and terms.
1 have read this applicant's statement and understand it.
2024-05-09
Date Time Applicant's Signature
it is a crime to knowingly provide false, incomplete or misleadirg information to an irsurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance benefts.
Rev 05110
Page 1 of 7
Effective: 05/15/2024
Document Ref: WAJD-EL2SD-F7CVL-9ZGBT Page 1 of 6