Agreement to Provide Insurance

AGREEMENT TO PROVIDE INSURANCE

CUSTOMER NAME:_________________________________________________________________________

ADDRESS:_________________________________________________________________________________

CITY, STATE & ZIP CODE:___________________________________________________________________

YEAR/MAKE/MODEL:_______________________________________________________________________

VIN#:______________________________________________________________________________________

AGENT INFORMATION

NAME:___________________________

ADDRESS:________________________

__________________________________

PHONE #:_________________________

INSURANCE COMPANY INFORMATION

NAME:_______________________________

POLICY #:____________________________

EFF DATE:_________ EXP DATE________

DEDUCTIBLES: COMP______COLL______

LIEN HOLDER: MIDWEST ACCEPTANCE CORP

                          1257 DOUGHERTY FERRY RD
                          P.O. BOX 9
                          VALLEY PARK, MO 63088-0009

I(WE) UNDERSTAND THAT I(WE) MUST PROVIDE COMPREHENSIVE AND COLLISION INSURANCE WITH A MAXIMUM OF $500 DEDUCTIBLES ON THE VEHICLE DESCRIBED ABOVE AT ALL TIMES. IT IS ALSO UNDERSTOOD THAT FAILURE TO PROVIDE ACCEPTABLE INSURANCE COVERAGE CAN RESULT IN MIDWEST ACCEPTANCE CORP DEMANDING THE ENTIRE BALANCE DUE AND PAYABLE IMMEDIATELY.

SIGNED______________________________________________________________________

DATED_______________________________________________________________________