Auto and Renters Insurance Policy

AUTO AND RENTERS INSURANCE POLICY

Policy Declarations

Policy Number:     Effective Date:     Expiration Date:

Phone:     Email:

Date of Birth:     Driver's License No.:

Policy Coverage Selection

Select coverage types included under this policy:

Auto coverage     Renters coverage

Auto Coverage Details

Coverages (select applicable):

Liability    Limit: $

Collision    Deductible: $

Comprehensive    Deductible: $

Uninsured / Underinsured Motorist    Limit: $

Medical Payments    Limit: $

Vehicle Information (Provide each vehicle insured)

VIN:    Primary Use:

VIN:    Primary Use:

Renters Coverage Details

Personal Property Coverage Limit: $    Deductible: $

Personal Liability Limit: $    Additional Living Expense Limit: $

Policy Limits, Premium & Payment

Total Annual Premium: $    Payment Frequency:

Exclusions and Limitations

This policy does not provide coverage for losses arising directly or indirectly from war, nuclear hazard, intentional acts by the insured, wear and tear, mechanical breakdown, or property of the insured used in the course of a commercial business unless explicitly endorsed. For auto coverage, there is no coverage for unlisted drivers, punitive damages unless required by law, or losses occurring while operating a vehicle without a valid license. For renters coverage, there is no coverage for property insured under a separate policy, theft by a person who resides in the residence, or property used for business purposes beyond declared limits.

Insured acknowledges receipt of the policy exclusions and limitations and agrees that coverage is subject to the full policy terms, conditions, endorsements and applicable limits.

I acknowledge the exclusions and limitations set forth above.

Beneficiary / Payable To (if applicable)

Payable on behalf of insured for covered accidental death or specified policy proceeds:

Relationship:    Share (%):

Claims Reporting & Documentation

Documentation submitted with claim:

Photographs     Receipts / Proofs of Purchase     Police Report     Repair Estimates

Policy Conditions, Duties & Certification

The insured shall: (1) pay premiums when due; (2) provide truthful and complete information and cooperate with insurer in investigation and defense of claims; (3) notify the insurer as soon as practicable following a loss and take reasonable steps to protect property from further damage; (4) permit inspection and examination under oath when requested; and (5) not admit liability or make settlements without the insurer's written consent.

The insurer may cancel or nonrenew this policy in accordance with the policy's cancellation provisions and applicable law. Premium adjustments, endorsements and corrections to this policy may be made in writing and become part of the policy when executed by an authorized representative of the insurer.

Fraud Warning: Misrepresentation, fraudulent statements, or omission of material facts in securing coverage or in the handling of a claim may result in denial of coverage, cancellation of the policy, and may subject the insured to civil or criminal penalties as permitted by law.

Certification: By signing below, the insured certifies that the information provided in this declaration and application is true and complete to the best of their knowledge and agrees that such information shall form the basis of the insurance contract. The insured authorizes the insurer to obtain motor vehicle and claims history information for underwriting and claims purposes where permitted by law.

I certify that the statements herein are true and consent to the terms and conditions of this policy.

Acknowledgement and Signature

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