401 Fayette Avenue Springfield, IL 62704

Please complete the following application: (*Required)

*** Answer may cause applicant to be ineligible for coverage.

$149.00 yearly

$100,000 Self‐Defense Coverage

$100,000 Personal Liability Protection

$50,000 Criminal Defense Reimbursement

$214.00 yearly

$250,000 Self‐Defense Coverage

 $250,000 Personal Liability Protection

$100,000 Criminal Defense Reimbursement

$279.00 yearly

$500,000 Self‐Defense Coverage

$500,000 Personal Liability Protection

$100,000 Criminal Defense Reimbursement

$344.00 yearly

$1,000,000 Self‐Defense Coverage

$1,000,000 Personal Liability Protection

$100,000 Criminal Defense Reimbursement

I hereby warrant that all of the foregoing statements contained in this application are complete and true and that these statements are offered by me as an inducement to the company to issue a policy for which I am applying. I understand that the company is relying on these statements to determine my acceptability for the coverage under the policy for which I am making an application. I further understand that if the statements contained in the application are subsequently found not to be complete and true, coverage under any policy issued as a result of this application could be compromised, or considered null and void.

Applicable in OH: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

By signing your name, you are acknowledging that you have read the foregoing statement and understand its content.

You also consent to have a Spriska representative contact you to process your premium and approve your policy.