Auto & Home Insurance Applications

AUTO & HOME INSURANCE APPLICATION

This application is made to obtain one or more insurance policies as indicated below. Completion of this form does not bind coverage. Coverage, limits, deductibles, endorsements and effective date will be determined by the insurer and confirmed in a policy or binder. Applicant must answer all questions fully and truthfully. Fraud or material misrepresentation in this application may be grounds for denial of coverage or rescission of any issued policy.

Applicant / Insured Information

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

Primary Phone:    Email:

Policy Details & Coverage Selection

Policy Type:   Auto   Homeowners / Dwelling   Both

Requested Effective Date:    Requested Term (months):

Automobile Details (List each vehicle)

Vehicle 1 — Year/Make/Model:   VIN:

Primary Use:   Annual Mileage:

Vehicle 2 — Year/Make/Model:   VIN:

Drivers Residing in Household

Driver 1 — Name:   DOB:

Driver 1 — License No./State:   Years Licensed:

Yes   No

Property / Home Details

Year Built:   Construction Type:   Occupancy:

Dwelling Coverage Amount:   Deductible:

Personal Property Limit (% of dwelling):   Liability Limit:

Coverage Options and Limits

Auto Coverages

Bodily Injury / Property Damage Limit (per accident):

Comprehensive Deductible:   Collision Deductible:

Uninsured/Underinsured Motorist Limit:   Medical Payments Limit:

Additional Auto Options:   Rental Reimbursement   Roadside Assistance   GAP Coverage

Home Coverages

Ordinance or Law Coverage: Yes   Replacement Cost Loss Settlement: Yes

Optional Endorsements:   Flood   Earthquake   Identity Theft

Prior Insurance & Claims History

Current or Most Recent Carrier:   Policy Period: From To

Yes   No

Lienholder / Beneficiary

Preferred Payee for Return of Premium or Loss Payee Name:

Relationship:   Percentage:

Declarations, Authorizations & Notices

Applicant hereby declares that the statements and particulars contained in this application are complete and true to the best of the applicant's knowledge and belief. Applicant understands that any material misrepresentation or omission may be grounds for denial of coverage, rescission of policy, or adjustment of any claim. The applicant agrees that this application shall be the basis of any policy issued and is subject to the terms, conditions and exclusions of that policy.

Applicant authorizes the insurer to obtain motor vehicle records, credit reports, prior loss information, underwriting reports, and claim histories as necessary to evaluate eligibility and premium. Information obtained may be used in the underwriting and claims handling process and shared with affiliates and agents as permitted by law. Applicant authorizes prior insurers and reporting agencies to provide relevant information to the insurer.

Duties after a loss: In the event of a loss, the insured must take reasonable steps to protect property from further damage, promptly notify the insurer, provide a sworn proof of loss when requested, cooperate with the insurer's investigation, and provide records and documents supporting the claim. Failure to comply with post-loss duties may result in denial of coverage.

Fraud Warning: Any person who knowingly presents false information or conceals material fact with the intent to defraud may be subject to civil or criminal penalties under applicable law.

Certification

By signing below, the applicant certifies that the information provided in this application is true and complete. Applicant acknowledges receipt of required notices and understands that the insurer may decline coverage, apply different terms, or adjust premium rates based on the information provided and insurer underwriting criteria. Applicant agrees that a digital or electronic signature shall be treated as an original.

Sign Now