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APPLICATION FOR GUARANTEED AUTO PROTECTION (GAP) PROGRAM
State Form 51819 (R/5-06) Approved by State Board of Accounts, 2006

State of Indiana DEPARTMENT OF FINANCIAL INSTITUTIONS 30 South Meridian Street, Suite 300 Indianapolis, IN 46204

DATE RECEIVED

_____________________ _ DFI ID # __ ____ ___

ATTACH APPLICATION FEE CHECK HERE

LIC ID #

INVOICE #_______________CHECK # ______________ AMT. PD _______________BAL. DUE _______________

GAP ADMINISTRATOR INFORMATION
Name Address (Number and Street) City, State, Zip Code Contact Person Telephone Number Fax Number

CONTRACTUAL LIABILITY INFORMATION
ATTACH A COPY OF THE INDIANA DEPARTMENT OF INSURANCE FILE STAMPED COPY OF CONTRACTUAL LIABILITY POLICY.

Name Address (Number and Street) City, State, Zip Code Telephone Number Fax Number

ACKNOWLEDGMENT
The applicant executed this application on and acknowledges that all statements made herein and supporting schedules, to the best of my/our knowledge and belief, are true and is a true and complete statement in accordance with the law.
Signature of Applicant By: Print or Type in Name of Signature E-Mail Address Title