PERSONAL SERVICE INSURANCE
PO BOX 1890
BLUE BELL, PA 19422-0479
APPLICATION FOR PRIVATE PASSENGER AUTO INSURANCE
APPLICANT NAME AND ADDRESS PRODUCER
FABIO DE LAVOR MELO GOOD2GO INSURANCE, INC. (900002)
87 WESTFIELD AVE PO BOX 1890
ELIZABETH, NJ 07208-3651 BLUE BELL, PA 19422
Home: 908-384-6669 888-303-3430
Cell: 908-384-6669 Producer Name: DEBORAH PONTE
Email: FABIODELAVORMELO1@[Link]
PREVIOUS ADDRESS (if less than Years) POLICY #:8873531
POLICY EFFECTIVE:
October 16, 2025 to April 16, 2026
1 - APPLICANT INFORMATION
First Middle Last Suffix Birth Date Marital Status Sex SSN
FABIO DE LAVOR MELO 06/13/1983 Single Male
2 - List all persons over 15 years of age who are residents of the same household, LICENSED OR NOT.
Name Relationship License State License Number Date Licensed
FABIO DE LAVOR MELO SELF NJ XXXXXXXXXXX6831 06/13/1999
3 - EMPLOYMENT INFORMATION
Applicant Employer
FABIO DE LAVOR MELO Occupation
Work Phone: Years in Current Occupation
Years with Current Employer
Years with Previous Employer
4 - VEHICLES
VEH VIN Year Make and Model Body Style Symbol
1 1FMCU9H92DUC07220 2013 FORD ESCAPE SEL AWD Utility Vehicle - Four Wheel Drive 4 Door 34/24
5 - VEHICLES (Cont.)
VEH Vehicle Use
1 Pleasure Use
6 - VEHICLE RATING
VEH Garaging Address (if different) State Registered Territory Rate Class Points
1 144 SM42 0
7 - ACCIDENTS/VIOLATION POINTS - PAST 36 MONTHS
Name Date Location Description Points
8 - COVERAGES - BASIC POLICY
Bodily Injury Liability Rejected
Verbal Threshold
Property Damage Liability 5,000 per occurrence
Personal Injury Protection
Medical Expense Limit $15,000.00
Medical Expense Deductible 2,500
Extended Medical Limit 1,000 Included
See PIP coverage Selection Form Attached
Roadside Assistance Rejected
9 - DISCOUNTS AND SURCHARGES
Vehicle 1 Double Airbag
10 - PREMIUMS
Coverage Veh 1
Property Damage Liability Premium $279.00
PIP Premium $494.00
Total ($773.00) $773.00
Deposit $160.00
Pay Plan 502 6 Month Same Day Due Date
Policy Tier 320
Credit Card Transaction Fee $5.00
11 -
I hereby certify that available policy coverages, options and exclusions have been explained to my satisfaction and that
the above coverages, limits and deductibles are of my selection. I understand that my policy will be issued to reflect the
options I have chosen with respect to the coverages shown in section 8 (Coverages) above. I further understand and
agree that my selection of all Coverage options, as shown above, shall be applicable to the policy of insurance on the
vehicle(s) described on all future renewals of the policy, on future policies issued me because of a change of vehicle or
coverage or because of an interruption of coverage, unless I subsequently request such coverages in writing.
APPLICANT'S SIGNATURE POLICY #: 8873531 DATE:
FABIO DE LAVOR MELO
(If under 18, Guardian's Signature is required)
12 - PRIOR COVERAGE
Name of Latest Policy Termination Date Plan Coverage Years Policy Written Through Your
Carrier Number Agency
No No
Prior Liability limits Did any vehicle carry Physical Damage No
Coverage?
13 - ADDITIONAL INTERESTS
Veh Type Name Address Loan Number Loan Balance
NONE
14 - GENERAL INFORMATION - During the past three years, has the applicant, any household member, or any driver:
Date vehicle(s) last inspected If yes, explain
Had auto insurance cancelled, been refused insurance or renewal, or received NO Reside in New Jersey LESS than 10 months per year? NO
notice of such intent?
If yes, explain
If yes, explain
Has vehicle(s) ever been salvaged? NO
Had license to drive or registration suspended, revoked or refused? NO
If yes, explain
If yes, explain
Any vehicle "Gray Market" (i.e. not manufactured for original sale in the NO
Had an accident or sustained a loss? NO U.S.)?
If yes, explain If yes, explain
Been fined, convicted, arrested or forfeited bail? NO Any vehicles listed on this application used for hire (taxi, limo, etc.), NO
commercial or business purposes, delivery (pizza, newspaper, etc.), or used
If yes, explain in the course or scope of your employment?
Have health problems or physical, mental or emotional handicap disability that NO If yes, explain
would impair driving ability?
Any residents of your household (licensed or not) that have NOT been NO
If yes, explain disclosed on this application?
Had any lawsuit during the past 5 years? NO If yes, explain
If yes, explain Have you failed to list any drivers such as children away from home or in NO
college, who may operate your vehicle on a REGULAR or INFREQUENT
Had any loan defaults in the past five years? NO
basis?
If yes, explain
Have you failed to list any other vehicles in the household? NO
If yes, explain
15 - REMARKS
16 - BINDER/SIGNATURE
INSURANCE BINDER IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:
EFFECTIVE DATE EXPIRATION DATE THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION.
10/16/2025 11/15/2025 THIS INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE
POLICY(IES) IN CURRENT USE BY THE COMPANY.
TIME
THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR
07:03 PM ET 12:01 AM
BY WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE
EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE
NOON INSURED IN ACCORDANCE WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED
WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY, THE
COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE
COVERAGE IS NOT BOUND RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM IS SUBJECT TO
VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY.
NOTICE OF INSURANCE INFORMATION PRACTICES
PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU. SUCH
INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR
AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW
YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE
DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE
UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE
POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION
FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR
IS DOMICILED IN THIS STATE WHEN IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER
THAN NEW JERSEY, IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
IN NO EVENT SHALL COVERAGE BE EFFECTIVE PRIOR TO THE DATE
AND HOUR OF COMPLETION OF THIS APPLICATION
APPLICANT'S STATEMENT
I hereby declare that the information provided to the Company when purchasing my Personal Auto Policy is true and do hereby
agree to pay any surcharges applicable under Company rules that are necessitated by inaccurate or incomplete statements. I
understand that my policy will be cancelled if I am unwilling to pay the additional premium.
I acknowledge that, in connection with my policy:
(1) I authorized the Company to obtain records of my driving history including motor vehicle reports for me and all drivers for
which coverage is afforded.
(2) With the purchase of a Standard Policy, I authorized the Company to obtain, review, and use consumer reports, credit
reports, and credit based insurance scores or to use a third party in connection with the development of my insurance score
for me and all drivers for which coverage is afforded.
(3) In certain circumstances, information may be disclosed to third parties (including affiliated companies) without authorization.
(4) I have the right to access and correct all personal information collected.
(5) At my request, the Company will:
a. confirm whether a consumer report, credit report, or credit based insurance score was requested, and if so, provide the
name and address of the consumer reporting agency from which it was obtained;
b. provide more detailed information regarding the collection, use and disclosure of personal information and my right to access
and correct such information. I also acknowledge that The Company may obtain consumer reports, credit report, or credit
based insurance scores in the future for updates, renewals or extension of this insurance.
I agree that if I pay my initial payment by check, draft or other remittance, the coverage afforded by this policy is conditioned
on the check, draft or other remittance being honored by the bank or financial institution when presented for payment. If a
check, draft or other remittance is not honored, the Company shall not be deemed to have accepted payment and the policy
shall be void from inception.
I agree to pay a late payment fee during the policy term and each renewal policy term when a payment is received by the
Company after the premium due date. The amount of the late payment fee may change upon renewal or an approved filing
change.
I declare that all vehicles listed in the Declarations for this Personal Auto Policy will have been titled and registered to the
named insured in New Jersey within 30 days of the policy inception and all such vehicles are garaged in New Jersey for a
minimum of ten (10) months per year. None of the vehicles listed in the Declarations are used for the pick-up or delivery of
goods, and none of the vehicles have altered suspensions, snowplowing equipment, cooking equipment or bathroom facilities.
I declare that all persons age 15 and over who live with me, licensed or not, and all regular and frequent operators of any
insured vehicles, are listed in the Declarations, and I declare that no person listed on this policy has been convicted of
insurance fraud. I have described any business or commercial use of my vehicle(s) on this application.
CONTACT CONSENT
I agree that by providing my e-mail address to the Company, I hereby give the Company, and its affiliates, consent to send
information regarding my policy to the e-mail address listed on this application. I agree that the Company and its affiliates may
use any telephone number I provide now or in the future to contact me by way of live calls or by use of any automatic dialing
system or artificial or prerecorded voice or text. I understand that this information may include, but is not limited to: premiums
due under my policy, the status of my policy and renewal information regarding this policy. I understand that the Company and
its affiliates will not sell or furnish my e-mail address or other contact information to any non-affiliated third party and that I may
opt out of receiving e-mail or text messages by notifying the Company of my intent.
FRAUD
The insurance policy is issued by Personal Service Insurance Company in reliance on the information provided in this
insurance application, including, but not limited to information regarding license and driving history of the undersigned, "family
members" and all persons of driving age in the undersigned's household; the description of the vehicles insured; the location of
the principal place of garaging; and the undersigned's place of residence.
Personal Service Insurance Company may deny coverage for an accident if the undersigned or any "insured" have concealed
or misrepresented any material or circumstance, or engaged in fraudulent conduct in connection with the presentation or
settlement of a claim.
To the extent that we make payments to you under this policy and our subsequent investigation reveals your involvement in
fraud or misrepresentation in the presentation of a claim, you must indemnify The Company for all payments made.
I have read the above application and I declare that to the best of my knowledge and believe all of the foregoing statements
are true. I further declare that I will notify Personal Service Insurance Company by phone or in writing if any information on this
application changes while the policy, or any renewal thereof, is in force.
Signature of Applicant POLICY#: 8873531 Date Hour
(If under 18, Guardian's Signature is required)
DEBORAH PONTE 900002 10/16/2025 7:04 PM ET
Signature of Agent Agent Number Date Hour
PSIC NJ APP (11/22)
BASIC POLICY COVERAGE SELECTION FORM
PERSONAL SERVICE INSURANCE
PO BOX 1890
BLUE BELL, PA 19422-0479
Name: FABIO DE LAVOR MELO POLICY #:8873531
This Coverage Selection Form is for a BASIC POLICY, see Buyer's Guide, page 4. A STANDARD POLICY with more
coverages and higher limits is also available for a higher premium. A SPECIAL POLICY with a very low premium is also
available through the Personal Automobile Insurance Plan (PAIP) for persons enrolled in Medicaid. Contact your agent
for more information.
CAUTION: If you choose the Basic Policy, you cannot collect Bodily Injury and Property Damage Liability, Personal
Injury Protection, and Uninsured and Underinsured Motorist Coverages under a Standard Policy.
1. BODILY INJURY LIABILITY- Buyer's Guide, page 2.
Yes, I choose the $10,000 Bodily Injury Liability Limit.
No, I do not choose to have Bodily Injury Liability Coverage.
WARNING: If you do not choose to purchase Bodily Injury Liability Coverage and you are at fault in
an accident where people are injured or die, you will be responsible for paying for the pain, suffering
and other personal hardships and some economic damages, such as lost wages that you cause.
The Company will not pay a judgment against you or pay for a lawyer to defend you if you are sued.
Your assets will be at risk, including having money deducted from your wages if a judgment is
entered against you.
WARNING: Insurers, producers, The Company, and their respective representatives shall not be
held liable for choices you make for insurance coverages or limits as long as your choices provide at
least the minimum coverage required by law. Insurers, producers, The Company, and their
respective representatives also shall not be held liable if you choose to purchase a Basic Policy
instead of a Standard Policy, or if you choose not to purchase Bodily Injury Liability Coverage,
Collision Coverage, or Comprehensive Coverage. Insurers, producers, The Company, and their
respective representatives can lose this limitation on liability for failing to act in accordance with the
law. See N.J.S.A. 17:28-1.9 for more information.
2PIP
2. PERSONAL INJURY PROTECTION- Buyer's Guide, page 2.
WARNING: For a BASIC POLICY, the limit on PIP Medical Expense Coverage is $15,000 but includes up to
$250,000 for emergency care of certain catastrophic injuries (See Buyer's Guide). Prior to March 22, 1999, all
automobile insurance policies had PIP Medical Expense limits of $250,000. The PIP Medical Expense Coverage
for a BASIC POLICY is significantly less than previously required by law.
Choose the PIP Medical Expenses Deductible you want:
$250 deductible, minimum required by law
$500 deductible, for a 3% to 4%, or a $20 to $60, reduction in the PIP premium
$1,000 deductible, for a 11% to 13%, or a $60 to $220, reduction in the PIP premium
$1,000 deductible, for a 11% to 13%, or a $60 to $220, reduction in the PIP premium
$2,000 deductible, for a 17% to 20%, or a $90 to $350, reduction in the PIP premium
$2,500 deductible, for a 20% to 24%, or a $110 to $420, reduction in the PIP premium
StmtInsured
3. STATEMENT OF INSURED OR APPLICANT
I have read the Buyer's Guide outlining the coverage options available to me. I understand that this is a BASIC
POLICY with minimum coverages required by law and that a Standard Policy with higher limits and additional
coverages is available. The option to buy Bodily Injury Liability Coverage has been explained to me. My choices are
shown above. I agree that each of these choices will apply for all vehicles insured by my policy and to each
subsequent renewal, reinstatement, continuation, replacement or amendment until my agent or The Company
receives my written request that a change be made.
For new policyholders, I understand that unless I choose to have the $10,000 Bodily Injury Liability Coverage, I will
not receive any Bodily Injury Liability Coverage.
I understand that if this is a policy renewal and if I do not complete choices, I will receive the same coverage as in my
previous policy except when changes are required by a law becoming effective during the term of my previous policy.
I understand that these choices take effect in the following manner:
(1) For new policies, the choices in this form are effective the day following receipt by The Company.
(2) For mid-term policy changes, the changes to be made on this form are effective at 12:01 am on the day after the
postmarked date.
(3) For changes upon renewal, the changes on this form are effective on the date of the next policy renewal if
postmarked or received by The Company prior to the renewal date.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN
INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE
CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN
FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO
CRIMINAL AND CIVIL PENALTIES.
Please check the appropriate box to which this form applies:
New Policy Mid-Term Change Renewal Change
To the best of my knowledge, no member of my household is a named insured under a Standard or Special Policy.
SIGNATURE OF NAMED INSURED OR APPLICANT ______________________________ DATE ____________
PSIC NJ BSEL (07/23)
Temporary State of New Jersey Insurance IMPORTANT NOTICE
Identification Card
The insurance policy meets the minimum insurance
Personal Service Insurance Company
requirements prescribed by New Jersey Law.
PO Box 1890
Blue Bell, PA 19422-0479
An Automobile Insurance Identification Card shall be
carried in each private passenger motor vehicle at all
CO Code:096 CO:NAIC 12289 Personal Service times. The operator of the insured vehicle shall exhibit
Insurance Co the ID card on the demand of any law enforcement officer.
POLICY # EFFECTIVE DATE EXPIRATION DATE ALL ACCIDENTS MUST BE REPORTED TO
8873531 10/16/2025 12/15/2025 PERSONAL SERVICE INSURANCE CLAIMS DEPARTMENT OR TO
YEAR: MAKE / MODEL: F YOUR LOCAL AGENT IMMEDIATELY.
O
2013 FORD ESCAPE SEL AWD L CALL 1-800-727-6664 * 365 DAYS A YEAR * 24 HOURS A DAY
VEHICLE ID NUMBER D
1FMCU9H92DUC07220 CUSTOMER SERVICE
H
1-800-777-6664
NAMED INSURED FABIO DE LAVOR MELO E
R Speak with a representative
87 WESTFIELD AVE Monday - Friday 8:00 a.m. - 6:30 p.m. (EST)
E
ELIZABETH, NJ 07208-3651
or obtain policy information through our Automated Phone System
THIS CARD EXPIRES 60 DAYS AFTER THE EFFECTIVE 24 HOURS A DAY * 365 DAYS A YEAR
DATE SHOWN ABOVE
900002 GOOD2GO INSURANCE, INC. ADDRESS FOR NOTIFICATION OF
PO BOX 1890 COMMENCEMENT OF MEDICAL TREATMENT:
BLUE BELL, PA 19422
888-303-3430 MEDLOGIX, LLC
300 AMERICAN METRO BLVD, SUITE 220
HAMILTON, NJ 08619
PHONE: 877-258-2378 FAX: 859-910-2501
Signature of Authorized Representative/Agent
KEEP THIS CARD IN THE VEHICLE AT ALL TIMES.
THIS CARD MUST BE PRODUCED UPON DEMAND.
Temporary State of New Jersey Insurance IMPORTANT NOTICE
Identification Card
The insurance policy meets the minimum insurance
Personal Service Insurance Company
requirements prescribed by New Jersey Law.
PO Box 1890
Blue Bell, PA 19422-0479
An Automobile Insurance Identification Card shall be
carried in each private passenger motor vehicle at all
CO Code:096 CO:NAIC 12289 Personal Service times. The operator of the insured vehicle shall exhibit
Insurance Co the ID card on the demand of any law enforcement officer.
POLICY # EFFECTIVE DATE EXPIRATION DATE ALL ACCIDENTS MUST BE REPORTED TO
8873531 10/16/2025 12/15/2025 PERSONAL SERVICE INSURANCE CLAIMS DEPARTMENT OR TO
YEAR: MAKE / MODEL: F YOUR LOCAL AGENT IMMEDIATELY.
O
2013 FORD ESCAPE SEL AWD L CALL 1-800-727-6664 * 365 DAYS A YEAR * 24 HOURS A DAY
VEHICLE ID NUMBER D
CUSTOMER SERVICE
1FMCU9H92DUC07220 H
E
1-800-777-6664
NAMED INSURED FABIO DE LAVOR MELO Speak with a representative
87 WESTFIELD AVE R
E Monday - Friday 8:00 a.m. - 6:30 p.m. (EST)
ELIZABETH, NJ 07208-3651
or obtain policy information through our Automated Phone System
THIS CARD EXPIRES 60 DAYS AFTER THE EFFECTIVE 24 HOURS A DAY * 365 DAYS A YEAR
DATE SHOWN ABOVE
900002 GOOD2GO INSURANCE, INC. ADDRESS FOR NOTIFICATION OF
PO BOX 1890 COMMENCEMENT OF MEDICAL TREATMENT:
BLUE BELL, PA 19422
888-303-3430 MEDLOGIX, LLC
300 AMERICAN METRO BLVD, SUITE 220
HAMILTON, NJ 08619
PHONE: 877-258-2378 FAX: 859-910-2501
Signature of Authorized Representative/Agent
KEEP THIS CARD IN THE VEHICLE AT ALL TIMES.
THIS CARD MUST BE PRODUCED UPON DEMAND.
PERSONAL SERVICE INSURANCE RECEIPT
Credit Card Transaction Fee $5.00
Credit Card Transaction Fee $5.00
NJ PLIGA Assessment $0.08
Deposit of $160.00 is Insufficient
Minimum REQUIRED
Deposit $165.00
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25 - RECEIPT / Insured Copy
26 - PAYMENT COUPON
Policy Number: 8873531
Insured's Name: FABIO DE LAVOR MELO Payment Amount: $131.00
87 WESTFIELD AVE
ELIZABETH, NJ 07208-3651
Due Date: 11/05/2025 Agent Name: 900002 GOOD2GO INSURANCE, INC.
PO BOX 1890
BLUE BELL, PA 19422
888-303-3430
Please mail this payment to:
Personal Serivce Insurance Co
PO Box 1890
Blue Bell, PA 19422-0479
Dear Policyholder,
We know that many facets of policy maintenance can be handled most effectively by you, the policyholder. For this
reason we are excited to announce the availability of our Policyholder Portal. The Policyholder Portal is a website 'portal'
our policyholders can use to manage important aspects of all of their policies...anytime day or night...even on holidays!
IMPORTANT PORTAL FEATURES
1. Make A Payment - Through the Policyholder Portal's secure transaction interface policyholders may post policy
payments using a variety of payment methods...and view policy payment histories.
2. Policy Documents - View policy information and download most policy related documents including ID Cards,
payment receipts and more.
3. Go Paperless - Manage the contact preferences that we will use to determine the delivery method for future
policy related documents and correspondence.
4. And Much More!
Thank you again for your business! We look forward to serving your insurance needs for many years to come.
A Policyholder Portal user account has been created in your name, for you to begin using immediately to manage your
policies. To get started using the Policyholder Portal, navigate to the Policyholder Portal login page using a recent
version of any major Internet browser:
[Link]
Once there, log into your Policyholder Portal account using the following credentials:
Account Holder: FABIO DE LAVOR MELO (FABIODELAVORMELO1@[Link]; 908-384-6669)
Your Username: FDELAVORMELO
Your Password (Case Sensitive): 07DE-Ki60