Automobile Insurance Policy Application

AUTOMOBILE INSURANCE POLICY APPLICATION

Applicant / Insured Information

Date of Birth:    Social Security Number (last 4 digits):

Driver Information (List all drivers to be insured)

Provide full details for the primary operator:

Has any driver to be insured had at-fault accidents in the last 5 years? Yes No

Vehicle Information

Provide complete details for each vehicle proposed for coverage.

Policy Coverage & Limits

Select requested coverages and indicate limits and deductibles where applicable. Coverage provided is subject to underwriting approval, policy terms, conditions and exclusions.

Premium & Payment

Beneficiary / Additional Interest

If Medical Payments or personal injury benefits are selected, designate primary beneficiary for first-party benefits (if applicable).

Exclusions and Important Notices

The policy for which you are applying will contain exclusions and limitations, including but not limited to: losses arising from intentional acts, racing or driving in organized events, use of the vehicle for hire other than as disclosed, operation by an unauthorized or excluded driver, wear and tear, mechanical breakdown, nuclear hazard, and losses resulting from war or civil insurrection. Coverage is also subject to policy conditions, deductibles and limits selected above.

Failure to disclose material information or any material misrepresentation may result in denial of coverage, rescission of the policy or adjustment of premiums and limits in accordance with policy terms and applicable law.

Declarations, Authorization & Certification

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that this application is the basis for any policy issued and that the insurer may rely on these statements in determining eligibility and premium. I authorize the insurer, its agents and representatives to obtain loss history, motor vehicle records, credit and underwriting information and other pertinent information for underwriting and claims purposes. I acknowledge that the insurer may disclose underwriting or claims information to affiliates and persons with a legitimate business purpose as permitted by law.

I understand that coverage will not be binding until a policy is issued and any required premium payment is accepted. If a policy is issued, it will be governed by the terms, conditions and exclusions contained in the policy contract issued by the insurer.

Supplemental Information

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