Home and Auto Insurance Proposal

HOME AND AUTO INSURANCE PROPOSAL

APPLICANT / INSURED INFORMATION

Insured Name:

POLICY DETAILS AND QUOTE

HOME COVERAGE OPTIONS

Dwelling Coverage Limit:   Deductible:

Personal Property Coverage   Limit:

Loss of Use (Additional Living Expenses)   Limit:

Personal Liability   Limit:

Medical Payments   Limit:

AUTO COVERAGE OPTIONS

List each vehicle to be insured. Provide year, make, model and VIN for underwriting.

COVERAGE SELECTION SUMMARY

Select coverages to be included in the proposal. Checkboxes indicate proposed inclusion; limits and deductibles shown above apply unless otherwise specified.

Homeowner's Package (Dwelling, Personal Property, Liability)

Personal Auto Package (Liability, Collision, Comprehensive)

Umbrella Liability (must be underwritten separately)

Roadside Assistance (Auto)

EXCLUSIONS AND LIMITATIONS

Unless specifically endorsed, the proposed policy will exclude coverage for loss or damage caused by: wear and tear, gradual deterioration, inherent vice, nuclear hazard, war or military action, intentional acts by the insured, and pollution loss except as may be specifically provided by endorsement. Flood and earthquake perils are excluded unless an endorsement providing such coverages is issued and premium collected.

Limits of liability, conditions, sublimits and additional exclusions will be set forth in the issued policy forms and endorsements. This proposal does not modify the terms, conditions or exclusions that will appear in the final policy.

PRIOR CLAIMS / LOSS HISTORY

Have you had any property or auto insurance claims in the past five years?    Yes    No

BENEFICIARY DESIGNATION (FOR CERTAIN LOSS PROCEEDS)

Identify the payee(s) to receive proceeds in the event of a covered total loss where a named beneficiary is required.

AUTHORIZATIONS, REPRESENTATIONS AND CERTIFICATION

I represent that the information provided in this proposal is true and complete to the best of my knowledge. I understand that this proposal, the representations herein and any supplemental information provided will be relied upon by the insurer in determining whether to issue a policy and on what terms. Any material misstatement or omission may result in denial of coverage or rescission of any policy issued on the basis of this proposal.

I authorize the insurer and its representatives to obtain and exchange underwriting, claims, loss history, motor vehicle and credit-related information necessary to evaluate this proposal, including but not limited to obtaining consumer reports and motor vehicle records where permitted by law. I consent to the release of requested records for underwriting and claims handling.

This proposal constitutes an offer to bind coverage only upon acceptance and issuance of a policy by the insurer and payment of any required premium. Coverage is not effective until the insurer issues a policy or endorsement and specifies an effective date.

DECLARATION

By signing below I declare under penalty of perjury that the statements in this proposal are accurate and complete. I understand that any final policy will be governed by the policy forms, endorsements, terms and conditions provided by the insurer. I further acknowledge that acceptance of this proposal is subject to underwriting review and approval.

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