Auto Insurance Policy Document

AUTO INSURANCE POLICY DOCUMENT

Policy Declarations

Insurer:    Policy Number:

Named Insured:    Agent/Broker:

Insured Information

Vehicle Information (List each vehicle insured)

Vehicle 1 — Year:    Make:    Model:

VIN:    Garaging Address:

Policy Period & Premium

Effective Date:    Expiration Date:

Coverage Summary

The following coverages are provided subject to the terms, conditions, exclusions and limits set forth in this policy.

  Bodily Injury & Property Damage Liability    Split Limits: $

  Collision (physical damage to insured vehicle)    Deductible: $    Limit: $

  Comprehensive (theft, vandalism, weather)    Deductible: $    Limit: $

  Uninsured/Underinsured Motorist Coverage — Limit: $

  Medical Payments — Limit: $

  Rental Reimbursement — Limit per day: $    Maximum: $

  Roadside Assistance — Included

Exclusions and Limitations

This policy does not provide coverage for losses arising out of the following, except to the extent coverage is provided by endorsement: intentional acts by the insured; operation of the insured vehicle for hire as a public conveyance unless specifically endorsed; use of the vehicle in a racing competition; loss or liability while the vehicle is operated by a person who does not hold a valid license where such lack of license is statutorily recognized as a bar to recovery; punitive or exemplary damages unless required by law to be paid by the insured. The insurer’s liability is limited to actual damages proven and within the limits expressed in this policy.

Acknowledgement of exclusions:   I have read and understand the exclusions and limitations set forth above.

Conditions of Coverage

1. Premium Payment: Coverage is conditioned upon payment of premium when due. Nonpayment of premium, whether for initial or renewal coverage, may result in cancellation or nonrenewal in accordance with policy provisions.

2. Changes in Risk: The insured must notify the insurer of any material change in risk, including change of residence, principal operator, or use of the vehicle. Failure to notify may result in denial of coverage for losses occurring after such change.

3. Subrogation and Cooperation: The insurer has the right to pursue subrogation against any third party responsible for a loss. The insured must cooperate fully with the insurer in investigation, settlement or defense of claims.

4. Fraud: Intentional misrepresentation or fraudulent acts by the insured relating to any claim or application for coverage shall render coverage void and may subject the insured to civil or criminal penalties.

Endorsements & Additional Provisions

Beneficiary / Loss Payee

Designated Primary Payee Name:

Relationship:    Percentage Payable:

Lienholder or Loss Payee (if applicable):

Claims Reporting & Documentation

In the event of a loss, the insured must provide notice to the insurer as soon as reasonably practicable and cooperate in the investigation. The following information is required for first notice of loss:

Documentation Checklist

  Police Report (if applicable)
  Photographs of Damage/Scene
  Repair Estimates / Invoices
  Medical Records / Bills (for bodily injury claims)

Certification and Applicant Statement

By signing below, the insured certifies that the information provided in this policy and any attachments is true and complete to the best of the insured’s knowledge. The insured acknowledges that material misrepresentation or omission of fact may result in denial of coverage or rescission of the policy. The insured authorizes the insurer to obtain driving records, claims history, and other information reasonably related to underwriting and claims handling. Acceptance of this policy is subject to payment of the required premium and to all terms, conditions, exclusions, and endorsements contained herein.

Notice Regarding Cancellation

This policy may be canceled by the insured at any time by returning the policy or by written notice to the insurer. The insurer may cancel or nonrenew this policy in accordance with the policy provisions and applicable law. Cancellation by the insurer for nonpayment of premium may be effective immediately upon notice where permitted by law.

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