Automobile Insurance Application Form

AUTOMOBILE INSURANCE APPLICATION FORM

Applicant Information

Applicant Name:

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

Policy Information

Requested Policy Type:

Requested Effective Date:    Requested Term End Date:

Preferred Payment Plan:

Vehicle Information (List each vehicle to be insured)

VIN:    License Plate:

Primary Use:    Odometer:

Drivers to be Insured

Date of Birth:    Relationship to Applicant:

Driver's License No.:    State Issued:    Years Licensed:

Coverage Selection

Please select coverages requested (limits and deductibles to be confirmed by underwriter):

Liability Bodily Injury & Property Damage    Limits:

Collision    Deductible:

Comprehensive    Deductible:

Uninsured/Underinsured Motorist    Limits:

Medical Payments / Personal Injury Protection    Limit:

Optional Coverages

Rental Reimbursement — Limit per day:

Roadside Assistance — Flat Limit:

Prior Insurance and Claims

Current or Prior Insurer:    Policy Number:

Exclusions, Notices and Acknowledgements

The following items are common exclusions that may apply and are not automatically covered unless specifically endorsed: use of a vehicle for hired transportation, intentional acts, wear and tear, use of a vehicle without permission, operation by an excluded driver, and loss due to war or nuclear hazard. The insurer may impose additional exclusions by endorsement.

Applicant Acknowledgement: I acknowledge that any material misrepresentation, omission of a material fact, or fraudulent statement in this application may result in denial of coverage, rescission of the policy, or denial of a claim. I agree that coverage is contingent upon acceptance by the insurer and issuance of a policy document which will establish all terms, conditions, limits, and exclusions.

Authorization: I authorize the insurer, its agents, and representatives to obtain motor vehicle records, credit information where permitted by law, and other underwriting information necessary to evaluate this application. I authorize release of my motor vehicle records to the insurer for underwriting and claim purposes.

Privacy Notice Acknowledgement: By signing this application I acknowledge receipt of any required privacy notices and consent to the insurer's use of my personal information for underwriting, policy administration, and claims handling as permitted by law.

Beneficiary Designation (if applicable)

Beneficiary Name:

Relationship:    Percentage:

Declarations and Certification

I declare that the statements made in this application are true and complete to the best of my knowledge and belief. I understand that this application will be the basis for any policy issued and that the insurer may use the information provided in its underwriting decision. I further understand that coverage will not be effective until accepted by the insurer and a policy or binder is issued.

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