Home & Auto Insurance Policy Renewal Form

Home & Auto Insurance Policy Renewal Form

Policy Number:    Insured Name:

Applicant / Insured Information

Policy Period & Premium

Renewal Effective Date:    Renewal Expiration Date:

Home Policy Details

Home Coverages (select applicable)

Auto Policy Details

Primary Garaging Address:

List Vehicles Covered (up to 3). Provide year, make, model, VIN.

Auto Coverages (select applicable)

Requested Changes / Endorsements

Exclusions & Material Conditions

The insurer reserves the right to decline or modify coverage for losses arising from:

• Intentional acts or willful misconduct by the insured;
• Wear and tear, gradual deterioration, mechanical breakdown or inherent vice;
• Losses due to nuclear hazard, war, or governmental action except as required by law;
• Property or vehicles used for commercial rental or livery unless specifically endorsed;
• Damage caused by flood or earthquake except where separate coverages are purchased.

Material misrepresentation or failure to disclose information material to risk may render this policy voidable and may result in denial of claims or cancellation. Insured must notify the insurer of any material change in risk, including changes in occupancy, principal use of the property, or vehicle usage.

Beneficiary for Refunds / Loss Proceeds (If Applicable)

Beneficiary Name:    Relationship:

Declaration and Authorization

I, the undersigned insured, declare that the information provided in this renewal form is true and complete to the best of my knowledge. I understand that any material misstatement or omission may be grounds for denial of coverage or rescission of the policy. I authorize the insurer to verify any statements, inspect insured property or vehicles, and obtain reports necessary to underwrite the policy.

I acknowledge that renewal is subject to underwriting review and payment of the required premium. I understand that coverages, limits, deductibles, and endorsements shown on the renewal are effective only upon issuance of the renewed policy or premium receipt as required by the insurer. I further agree to notify the insurer promptly of any material change in circumstances.

Fraud Warning: Any person who knowingly presents false information in an application for insurance or submits a fraudulent claim may be guilty of insurance fraud and subject to civil and criminal penalties under applicable law.

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