Auto & Home Insurance Application Form

Auto & Home Insurance Application Form

Applicant / Insured Information

Date of Birth: / Social Security Number (last 4):

Policy Details

Desired Effective Date:    Policy Term (months):

Vehicle Information (Vehicle 1)

Ownership:    Primary Use:

Vehicle Information (Vehicle 2) — Optional

Drivers

Date of Birth:    Driver's License No.:    Issuing State:

Home Property Information

Year Built:    Construction Type:

Smoke detectors    Burglar alarm    Fire sprinkler system    Central monitoring/security service

Coverage Selections

Select desired coverages for Auto:

Liability    Limits: $    Collision    Deductible: $

Comprehensive    Deductible: $    Uninsured/Underinsured Motorist    Limit: $

Select desired coverages for Home:

Dwelling Coverage    Limit: $

Personal Property    Limit: $    Loss of Use    Limit: $

Premiums & Payment

Estimated Premium (annual): $    Payment Frequency:

Prior Insurance & Claims History

Any claims or losses in the past 5 years?    Yes    No

Exclusions & Limitations

The coverages applied for are subject to the terms, conditions, exclusions and limits contained in the policy. Typical exclusions include, but are not limited to: intentional loss, wear and tear, mechanical or electrical breakdown, war, nuclear hazard, loss from illegal activity, and loss while the vehicle is used in any professional racing or competitive event. Coverage for flood, earthquake, sinkhole, and certain water or sewer backups may be excluded unless specifically endorsed.

Beneficiary Designation

Designate beneficiary for any return of premium or named payee provisions under the policy.

Declarations, Authorizations & Fraud Notice

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that this application, any declarations, and any attachments will form the basis of any policy issued. I acknowledge that any material misrepresentation or omission may result in denial of coverage or rescission of the policy, and that fraudulent statements may be subject to criminal penalties under applicable law.

I authorize the insurer, its representatives and agents to obtain and exchange information about my driving history, claims history, credit-related information, and other relevant consumer reports from third parties for underwriting, rating, and claims handling purposes. I also authorize inspection of the covered property or vehicle by a licensed adjuster or inspector, and access to repair estimates and invoices if a claim is made.

By signing below I acknowledge that I have read and understand the scope of the coverages requested, the applicable deductibles, and that actual coverage is subject to the policy contract, endorsements, and conditions.

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