Auto Insurance and GL Documents

AUTO INSURANCE AND GENERAL LIABILITY APPLICATION AND DECLARATIONS

Applicant / Insured Information

Policy Details

Policy Type:   Policy Number:

Policy Period: From to

Vehicle Information (Auto Coverage)

Vehicle 1 — Year/Make/Model: VIN:

Primary Use: Annual Mileage:

Coverage Selection

Select desired coverages. Checking a box indicates you request the coverage; final terms subject to underwriting and policy language.

Claims History and Loss Information

Have you had any automobile or general liability claims, accidents or losses in the past five years?    Yes    No

Exclusions and Limitations

The following exclusions are common to the coverages applied for. Coverage will be subject to the full terms, conditions, exclusions and endorsements of the issued policy.

• Losses arising from intentional acts, willful misconduct or criminal acts by an insured are excluded.
• Liability for punitive or exemplary damages is excluded unless coverage is expressly provided by endorsement.
• Coverage for use of vehicles for hired transport (e.g., livery/hail) is excluded unless specifically endorsed.
• Property damage to property owned by the insured or in the insured's care, custody, or control is excluded unless specifically provided.

I acknowledge that I have read and understand the exclusions above and that final coverage is subject to the insurer's policy language and underwriting determination.

Beneficiary / Additional Insured

If a beneficiary, loss payee or additional insured is to be named, provide the information below. This information does not constitute endorsement; acceptance is subject to endorsement issuance and premium adjustment.

Documentation Checklist (for Claims / Endorsements)

Please indicate documents you will provide if a claim or endorsement request is submitted:

Declaration and Certification

I certify that the information provided in this application is true, correct and complete to the best of my knowledge. I understand that any material misstatement, omission or concealment of fact may constitute fraud and may be grounds for denial of coverage or rescission of the policy pursuant to applicable law.

I authorize the insurer, its agents and representatives to obtain and exchange information necessary for underwriting and claim handling, including but not limited to driving records, prior loss history and other insurance data. I understand that coverage, limits, terms, conditions, endorsements and premiums will be determined by the insurer in accordance with its underwriting guidelines and the policy contract.

I agree to cooperate in the investigation and defense of claims and to permit the insurer to pursue subrogation or recovery from any third parties to the extent permitted by law. I understand that acceptance of this application and issuance of a policy is subject to underwriting approval and receipt of premium as required.

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