ORDER FORM

Plan A - $35 Towing Benefit, Plan B - $50, Plan C - $75, Plan D - $100 Benefit.

Plan A Price: $19.95/yr Quantity: Year: Make: Model:
Plan B Price: $24.95/yr Quantity: Year: Make: Model:
Plan C Price: $34.95/yr Quantity: Year: Make: Model:
Plan D Price: $39.95/yr Quantity: Year: Make: Model:
Instructions: Print and complete form. Mail completed form along with a check or money order payable to: Kerry Wilson Insurance, 108 S. 5th Street, Gadsden, AL 35901 (phone: 256-546-2811, or 888-218-6711). Upon receipt, your identification card(s), and contract(s) will be mailed to you. Coverage is effective when you receive the contract. This is a motor club, and it is not an insurance policy. You may also order by phone with a credit card. Call Kerry Wilson at 888-218-6711.

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