Home and Auto Insurance Application

HOME AND AUTO INSURANCE APPLICATION

Applicant / Insured Information

Month:    Day:    Year:

Policy Period and Agent Information

Requested Effective Date: Month Day Year

Home (Property) Details

Dwelling Type: Single-family    Condominium    Multi-family    Mobile/Home

Smoke detectors    Burglar alarm    Deadbolt locks    Fire sprinkler system

Auto Details (Up to 3 Vehicles)

Vehicle 1

Owned    Leased    Financed

Vehicle 2 (optional)

Vehicle 3 (optional)

Named Drivers

Provide each driver who will operate insured vehicles. Attach additional page if needed.

Month:    Day:    Year:

Coverage Selections — Home

Select desired coverages and enter requested limits. Coverage is subject to underwriting, policy terms and conditions.

Deductible:    Liability Limit:

Request Flood Coverage endorsement    Request Earthquake endorsement    All other perils replacement cost

Coverage Selections — Auto

Select limits and options. Limits shown as per person / per occurrence where applicable.

Comprehensive and Collision   Collision Deductible:   Comprehensive Deductible:

Uninsured/Underinsured Motorist    Rental Reimbursement    Roadside Assistance

Prior Insurance & Claims History

Yes    No

Mortgagee / Loss Payee / Beneficiary Information

List any mortgagee, lienholder, additional insured, or beneficiary to be named on the policy or loss payment. Attach additional sheets as required.

Exclusions and Important Notices

The policy applied for will contain exclusions and limitations. Typical exclusions include loss or damage resulting from: intentional acts, wear and tear, gradual deterioration, nuclear hazard, war, governmental action, or pollution unless specifically endorsed. Flood and earthquake are not covered unless an appropriate endorsement is purchased and listed on the policy declarations. Coverage for business pursuits or rental occupancy may be limited or excluded unless separately endorsed.

Declarations, Authorization and Certification

By signing below, the Applicant certifies that the information contained in this application is complete and true to the best of Applicant's knowledge and belief. Applicant acknowledges that the insurer will rely on these statements in determining eligibility for coverage and premium. Applicant authorizes any prior insurer, employer, or other entity to release motor vehicle and loss history, claim information, credit-related information, and other underwriting-related information to the insurer and its agents for underwriting, rating, and claims handling purposes, consistent with applicable law.

Applicant understands and agrees that coverage is not effective until the insurer accepts this application and issues a policy. Any acceptance may be subject to underwriting review, inspection, and payment of premium. Applicant further acknowledges that any material misrepresentation or omission on this application may be the basis for denial of claims or rescission of the policy as permitted by law.

Fraud Warning: Where applicable by law, knowingly providing false, incomplete, or misleading information to obtain insurance coverage or to make a claim may constitute fraud and may be subject to criminal or civil penalties.

Sign Now