Auto Remarket Application Form

AUTO REMARKET APPLICATION FORM

Applicant / Insured Information

Individual Corporation Other:

Policy Details Requested

Coverage Options (select all that apply)

Liability Collision Comprehensive Uninsured/Underinsured Motorist

Medical Payments Roadside Assistance Rental Reimbursement

Vehicle Information (List each vehicle to be remarketed)

If additional vehicles are to be included, attach a separate schedule with VIN, year, make, model, mileage and estimated value. Failure to disclose material vehicle information may result in denial of coverage.

Prior Insurance and Loss History

In the past five (5) years, has the applicant had any accidents, claims, or motor vehicle convictions? Yes No

Required Documentation Checklist

Vehicle title(s)

Odometer disclosure(s)

Photographs of vehicle(s) condition

Maintenance / service records (if available)

Exclusions and Program Limitations

Standard exclusions applicable to remarketed vehicles include but are not limited to: mechanical breakdown not caused by a covered peril, pre-existing damage known to the applicant at the time of application and not disclosed, theft or conversion by the applicant or their agents, and any loss arising from illegal acts of the insured. Coverage provided under this application is subject to underwriting approval and the insurer's policy terms, conditions, limitations and endorsements.

I acknowledge that I have read and understand the exclusions and limitations described above.

Beneficiary / Payee for Total Loss Proceeds

Declarations, Authorizations and Certification

By submitting this application the applicant represents and warrants that all statements and answers contained herein are true, complete and correct to the best of the applicant's knowledge. The applicant authorizes the insurer and its representatives to obtain and verify underwriting information, including but not limited to prior insurance claims history, vehicle records and other consumer reports necessary for underwriting and claim handling. Failure to disclose material information or submission of fraudulent information may void coverage and be subject to civil and criminal penalties.

The applicant understands that submission of this application is an offer to procure insurance and is subject to the insurer's underwriting acceptance and issuance of a policy. Coverage, if bound, will be subject to policy terms, conditions, endorsements, and applicable limits. The insurer reserves the right to decline, modify, or attach additional terms as a condition of binding.

Applicant Printed Name:   Date of Application:

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing materially false information may be guilty of insurance fraud and subject to fines, civil penalties and criminal prosecution.

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