Auto and Renters Application Form

AUTO AND RENTERS APPLICATION FORM

Recitals

WHEREAS, Applicant seeks consideration for underwriting and placement of personal automobile insurance and renters insurance (together, the Coverage); and

WHEREAS, Agency/Company acts as an agent or broker to collect the information necessary to evaluate risk, provide quotes, and bind Coverage upon approval; and

WHEREAS, the parties agree that the information supplied in this Application will be relied upon for underwriting, premium calculation, and policy issuance.

Applicant Information

Co-Applicant / Household

Automobile Information (List up to 3 vehicles)

Vehicle 1 — Year: Make: Model: VIN:

Vehicle 2 — Year: Make: Model: VIN:

Vehicle 3 — Year: Make: Model: VIN:

Renters Property Information

Unit Type: Number of Occupants: Pets?

Drivers and Household Members

Primary Driver Name: DOB: License #:

Additional Driver Name: DOB: License #:

Coverage Selection

Auto Coverage — Liability Limit: Comprehensive Deductible: Collision Deductible:

Renters Coverage — Personal Property Limit: Liability Limit: Medical Payments:

Rental Reimbursement Roadside Assistance Identity Theft Coverage

Prior Insurance and Loss History

Yes No

Scope of Services

The Agency/Company will collect applicant information, request underwriting quotations from insurers, and present options for coverage. The Agency/Company does not bind coverage until acceptance of terms and receipt of any required premium or binder authorization.

Payment Terms

Applicant agrees to pay premium and fees as required by selected insurer(s). The Agency/Company may collect an initial deposit or full premium as a condition to bind coverage.

Term and Termination

Coverage effective and expiration dates are set by the issuing insurer and are subject to underwriting approval. Applicant may withdraw this Application prior to binding by providing written notice to the Agency/Company.

Effective Date: Expiration Date: Notice Period for Cancellation:

Confidentiality

Applicant information, including personal, financial and claims history data, will be treated as confidential and used only for underwriting, policy administration, claims handling, and as required or permitted by law. The Agency/Company may disclose information to insurers, reinsurers, claim administrators, or as required by regulatory authorities. Confidential information will not be disclosed to unrelated third parties for marketing without Applicant's express written consent.

Governing Law

This Application and any resulting policy or agreement will be governed by and construed in accordance with the laws of the state in which the primary residence is located, without regard to conflict of law principles.

Entire Agreement

This Application, together with any declarations, endorsements, or policy documents issued by the insurer, constitutes the entire understanding between Applicant and the Agency/Company with respect to the matters contained herein and supersedes all prior discussions and representations, whether oral or written.

Certifications and Authorization

Applicant certifies that all information provided in this Application is true, complete and accurate to the best of Applicant's knowledge. Applicant understands that misrepresentation, material omission, or fraud may result in denial of coverage, rescission, or claim denial. Applicant authorizes the release of claim and underwriting information to insurers and authorizes insurers to obtain motor vehicle records and other consumer reports necessary for underwriting, rating, and claims handling.

Additional Disclosures

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