Auto and Condo Insurance Application

Auto and Condo Insurance Application

Applicant / Insured Information

Date of birth:    Primary phone:    Email:

Policy Details

Policy type (select all that apply):   Auto   Condo (HO-6)   Combined Auto & Condo

Requested policy period start:    end:

Auto Coverage Selections

Liability limit: $ per person / $

Deductible (collision): $    Deductible (comprehensive): $

Coverages requested:
Collision   Comprehensive   Bodily Injury Liability   Property Damage Liability   Uninsured/Underinsured Motorist   Medical Payments / Personal Injury Protection

Vehicle Information (List all vehicles to be insured)

Vehicle 1

Primary use:    Annual mileage:

Vehicle 2 (if applicable)

Primary use:    Annual mileage:

Condo Unit / Property Information

Unit number:    Year built:    Square footage:

Condo Coverages & Limits

Coverage for dwelling/fixtures (HO-6 building items) limit: $    Personal property limit: $

Deductible (property): $    Loss assessment coverage: $

Additional condo coverages requested:
Loss of Use / Additional Living Expenses   Water Backup / Sump Overflow   Ordinance or Law Coverage   Identity Theft Expense

Driver and Household Information

Primary driver

Date of birth:    Driver's license #:    State:

Are there other household drivers to be insured? Yes    No

Claims History / Loss Information

Yes   No

Documentation Checklist

Please indicate documents provided or to be provided:
Vehicle registration(s)   Vehicle title / lease agreement   Condominium declaration / HOA statement
Photos of property / vehicles   Repair estimates / invoices

Beneficiary Information

Relationship:    Percentage:

Exclusions and Important Notices

The proposed policy will not provide coverage for losses caused by or resulting from: flood or surface water unless specifically endorsed; intentional loss, wear and tear, gradual deterioration, mechanical or electrical breakdown; war, nuclear hazard, or seizure/confiscation by civil authority; unauthorized use or commercial livery operations unless specifically endorsed. Additional exclusions and limitations will apply as set forth in the policy form.

Acknowledgment of common exclusions: I acknowledge I have read and understand the exclusions described above.

Declarations, Authorizations and Certification

I declare that all statements and answers in this application are true and complete to the best of my knowledge. I agree that this application, and any material written statements submitted with it, shall form the basis of any policy issued. I understand that any materially false statement, or material omission, may be grounds for denial of coverage, cancellation of coverage, or rescission of the policy as permitted by law.

I authorize the insurer and its representatives to obtain motor vehicle reports, claims history, credit information, and other investigative reports necessary to underwrite and service the policy. I further authorize disclosure of information to other insurers for purposes of underwriting, claims handling, fraud prevention, and regulatory reporting.

I understand that coverage is effective only if and when the company accepts this application and issues a policy or binder. Coverage may be subject to additional terms, conditions, and endorsements as provided in the policy. I acknowledge that premiums are due according to the terms agreed upon and that failure to pay premium may result in cancellation for nonpayment.

Fraud warning: Where permitted by law, fraudulent statements or omissions in this application may be grounds for denial of claim and policy rescission. I certify under penalty of perjury under applicable law that the foregoing is true and correct.

Additional Information

Signature and Certification

By signing below, the applicant certifies that the information provided in this application is complete and accurate, and authorizes the insurer to use the information for underwriting and claims purposes as described above.

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