VEHICLE REPLACEMENT GUARANTEE
Mercury Select Management Company, Inc.
SELLER INFORMATION
PURCHASER / LESSEE INFORMATION
NAME
NAME
ADDRESS
ADDRESS
CITY / STATE ZIP
CITY / STATE ZIP
PHONE NUMBER
SELLER NUMBER
PHONE NUMBER
LICENSED SALESPERSON’S NAME (FLORIDA ONLY)
VEHICLE INFORMATION
CONTRACT INFORMATION
Lienholder/Creditor Name / City / State / Zip
Vehicle Replacement Guarantee Number (from Decal)

NEW
#
Purchase Date

PRE-OWNED
Year
Purchase Price (up to $150,000)
$
Make
Term (Months)
(check one)
Model
Agreement
Mileage
17-Digit Vehicle Identification Number
 24
Contract Cost
$
 36
 48
Effective:
/
/
 60
Expires:
/
/
 72
Tax (if applicable) $
TOTAL COST
$
A Vehicle Protection Product has been affixed on the Covered Vehicle windows and/or body parts and includes warning decals affixed to the driver and passenger windows of the
Covered Vehicle.
This is Your receipt for purchase and installation of the Vehicle Theft Protection System. The terms and conditions contained herein will apply to the approved Guarantee.
In order for this guarantee to be valid, the application must be accepted by Mercury Select Management Company, Inc., (MSMC) P.O. Box 728866, Oklahoma City, OK 73172,
1-800-654-8455. This guarantee is not subject to any verbal representations made by the seller. MSMC is insured to the extent of its obligations under a warranty reimbursement
insurance policy issued by American Mercury Insurance Company, P. O. Box 728847, Oklahoma City, OK, 73172, 1-800-654-8455. In the event a claim or any other obligation of
the Warrantor is not paid within sixty (60) days after proof of loss has been filed with the Warrantor, You shall be entitled to make a claim directly against American Mercury
Insurance Company by contacting it at the address or phone number above.
In Massachusetts, North Carolina, South Carolina and Maryland the obligations of the Warrantor under this Warranty are not insured under a warranty reimbursement
insurance policy issued by American Mercury Insurance Company but are backed by the full faith and credit of the Warrantor.
GUARANTEE FOR NEW AND PRE-OWNED VEHICLES
In the event of a Total Theft of the Covered Vehicle as the result of the theft of the Covered Vehicle when the Vehicle is not recovered, or if the Vehicle is recovered but
declared a Total Loss due to damage incurred as a result of the theft, and subject to the provisions contained herein, MSMC will pay You the following: 1. the deductible applicable
to your comprehensive motor vehicle insurance coverage (up to $1,000), and ; 2. rental coverage for a temporary licensed vehicle (up to $500). . Taxes, license, registration,
document fees; and either 2(a) or 2(b), as follows: 2(a). for New vehicles, the difference between the Actual Cash Value of Your Vehicle at the time of the theft and the
M.S.R.P. of the New Replacement Vehicle less any factory incentives up to the Guaranteed Maximum Payment; OR 2(b). for Pre-owned vehicles, the difference between the
Actual Cash Value of Your Vehicle at the time of the theft and the Pre-owned Replacement Vehicle Value up to the Guaranteed Maximum Payment. The
Guaranteed Maximum Payment, whichisthesumofallbenefitspayableunderthisGuarantee, is limited to $7,500 for all vehicles.
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THIS AGREEMENT IS A PRODUCT WARRANTY AND NOT AN INSURANCE POLICY.
THIS GUARANTEE IS SUBJECT TO THE TERMS AND CONDITIONS PROVIDED IN THIS DOCUMENT.
To be eligible for coverage under this Guarantee Your Vehicle must be covered by a comprehensive motor vehicle insurance policy at the time of the theft.
This Guarantee applies to only thefts occurring in the Continental USA, Alaska and Hawaii.
This Guarantee may be cancelled by You at any time. If You cancel within sixty (60) days of purchase, and no claims have been paid, We will refund the
total charge made for this Guarantee and this Guarantee will be considered Void, you will be refunded 100% of the premium paid, less any claims, after
the first sixty (60) days you will be refunded a prorated refund of the unearned premium paid. Guarantor may cancel due to non-payment of the purchase
price, fraud or material misrepresentation. In the event this agreement is cancelled by the Guarantor, you will be provided written notice 30 days
prior to the effective date of the cancellation. The notice will include the reason(s) and the effective dates of such action.
This Guarantee may be transferred by submitting a $40 transfer fee payable to MSMC within fifteen (15) days of the sale of the vehicle along with a copy of
the bill of sale stating the name, address and contact information of the new purchaser/lessee.
The New or Pre-owned Replacement Vehicle must be purchased from the Dealer or Entity selling the Vehicle Theft Protection System. In the event that the
selling Dealer or Entity is not available to supply a New or Pre-owned Replacement Vehicle, contact MSMC at 1-800-654-8455 for further instructions.
You must take delivery of a New or Pre-owned Replacement Vehicle within thirty (30) days from the date the Total Loss settlement check is issued by the
insurance company insuring Your Covered Vehicle. If You do not take delivery of this New or Pre-owned Replacement Vehicle within such time, You will
not be entitled to any reimbursement under this Guarantee.
Rental coverage applies only to vehicles rented from a licensed rental agency, excluding insurance or fuel costs.
This Guarantee will not be honored if the Covered Vehicle is seized by any government agency. This Guarantee is void in jurisdictions where its terms may
be in conflict with State or Federal law.
I have read the above GUARANTEE and the terms and conditions provided herein and I choose to purchase the Vehicle Security System. I have read the GUARANTEE for the
Vehicle Security System and understand it is not an Insurance Policy. The purchase of this product is not required to purchase or obtain financing of your vehicle.
Applicant Signature
ORIGINAL: ADMINISTRATOR
VRG.35.150 0213
Seller’s Signature
COPY: CUSTOMER
Date
COPY: LENDER
COPY: SELLER
FL Lic. No. 60049
The maximum term of this Guarantee is the number of months from the date of purchase indicated on the front of this Guarantee. This Guarantee is IN LIEU OF,
AND ALL PARTIES HERETO SPECIFICALLY DISCLAIM, ALL OTHER WARRANTIES, EXPRESSED OR IMPLIED, INCLUDING ANY WARRANTY
OF MERCHANTABILITY AND ANY WARRANTY OF FITNESS FOR A PARTICULAR PURPOSE and all other remedies, obligations or liabilities on the
part of any party hereto. In addition, You agree that there is no liability hereunder for consequential damages, for breach of any expressed or implied warranty,
including any implied warranty of merchantability and any implied warranty of fitness for particular purpose, with respect to the Vehicle Security System. The
duration of any implied warranty which may exist by operation of law shall be limited to the term set forth herein from the date of purchase. Some states do not allow
the exclusion or limitation of consequential damages, and some states do not allow limitations on how long an implied warranty lasts, so the above limitations or
exclusions may not apply to You.
EXCLUSIONS
This Vehicle Theft Protection System is sold with a Guarantee, however, the Guarantee absolutely does not apply to the following:
• Claims as a result of fraud or misrepresentation.
• Any service contract or service agreement.
• Transportation fees other than those charged by the manufacturer on New Replacement Vehicles.
• Vehicle conversions, accessories, or improvements in the Replacement Vehicle unless such accessories were permanently affixed to the stolen
vehicle by the manufacturer.
DEFINITIONS
We, Us and Warrantor means Mercury Select Management Company, Inc. (MSMC)
You, Your and Warranty Holder means the purchaser of this Warranty.
Covered Vehicle or Vehicle means the vehicle set forth in this Guarantee
Warranty and Guarantee mean this Agreement
Replacement Vehicle means either a New Replacement Vehicle or a Pre-owned Replacement Vehicle.
New Replacement Vehicle means the vehicle purchased to replace the stolen Covered Vehicle at the time of the loss. The Replacement Vehicle must be a new
vehicle of the same make and model as the Covered Vehicle, including and strictly limited to the identical options and accessories affixed to the stolen Covered
Vehicle by the vehicle manufacturer. The New Replacement Vehicle year model will be determined by adding one year model to the year model of the Covered
Vehicle for every 12 calendar months of ownership.
Pre-owned Replacement Vehicle means the vehicle purchased to replace the stolen Covered Vehicle at the time of the loss. The Pre-owned Replacement vehicle
must be a vehicle which is the same number of years old as the Covered Vehicle at the time it was originally purchased, including and strictly limited to the identical
options and accessories affixed to the stolen Covered Vehicle by the vehicle manufacturer. The Pre-owned Replacement Vehicle year model will be determined by
adding one year model to the year model of the Covered Vehicle for every 12 calendar months of ownership.
Pre-owned Replacement Vehicle Actual Cash Value means the retail book value of the replacement vehicle as listed in the N.A.D.A. Official Used Car Guide in
Your state adjusted for all factory-installed accessories included on Your Covered Vehicle when originally purchased, including any mileage adjustments.
Total Loss means a total loss of the stolen Covered Vehicle as determined by Your comprehensive motor vehicle insurance company resulting from the theft of
the Covered Vehicle.
Actual Cash Value of Your Vehicle means the retail book value of Your Covered Vehicle at the time of the theft as listed in the N.A.D.A. Official Used Car Guide
in Your state adjusted for all factory-installed accessories included on Your vehicle when originally purchased, including any mileage adjustments.
M.S.R.P. means Manufacturer’s Suggested Retail Price.
N.A.D.A. means National Automotive Dealers Association’s Official Used Car Guide.
Vehicle Theft Protection System or Vehicle Security System means warning decals affixed to the driver and passenger windows of the Covered Vehicle.
CLAIMS PROCEDURES
All claims must be reported to MSMC at 1-800-654-8455 Claims Customer Service Department within thirty (30) days of the loss. To complete the claim report, you
must provide the following documentation:
A. Copy of the written police report regarding the theft.
B. Copy of the claim settlement papers/check from Your insurer issuing Your comprehensive motor vehicle insurance policy.
C. Copy of receipt for purchase and installation of the Vehicle Theft Protection System.
D. Copy of receipt for purchase or lease and delivery of the Replacement Vehicle (including applicable taxes and fees).
E. Copy of the factory installed options/equipment for the stolen vehicle and the Replacement Vehicle.
F. Copy of the Rental Vehicle Agreement, if applicable.
G. All additional documents requested to verify claim.
CAlIFORNIA – THIS AGREEMENT IS NOT SUBJECT TO CALIFORNIA STATE INSURANCE LAWS BUT IS SUBJECT TO THE CALIFORNIA STATE
LAW CONCERNING WARRANTIES. MSMC’s provider license number is OE48157. If You are not satisfied with the insurance company issuing the warranty
reimbursement insurance policy or MSMC regarding any claim or any other matter under this agreement, You may contact the California Department of Insurance
at 1-800-927-4357.
FlORIDA – License Number 60049. You may not make a claim under the Florida Insurance Guaranty Association in relation to this Agreement.
NEW JERSEY – This warranty is under the purview of the New Jersey Division of Consumer Affairs.
OREGON – The warranty Holder may address unresolved complaints regarding the warrantor or this product or questions concerning the regulation of this product
of the warrantor to the Department of Consumer and Business Affairs, P. O. Box 14480, Salem, OR, 97309, (503) 378-6444.
TEXAS – The warranty Holder may address unresolved complaints regarding the warrantor or this product or questions concerning the regulation of this product
of the warrantor to the Texas Department of licensing and Regulation, P. O. Box 12157, Austin, Tx, 78711, (800) 803-9202, (512) 463-6599.