Insurance Application Acuity Apps

INSURANCE APPLICATION ACUITY APPS

Applicant / Insured Information

Applicant Name:

Date of Birth:    Tax ID / SSN:

Policy Details

Policy Period From:    To:

Coverages Requested

Select coverages to be quoted and indicate limit where different from Coverage Amount provided above.

Exclusions and Acknowledgements

The applicant acknowledges that standard policy forms contain specified exclusions. Applicant must indicate acknowledgement of the primary exclusions below.

By checking each box above the applicant confirms they have read and understand the listed exclusions and that additional exclusions may apply as indicated in final policy language.

Prior Insurance & Loss History

Beneficiary Designation

Provide primary beneficiary details for any applicable policy proceeds. Percentages should total 100% where required by the policy.

Declarations & Authorization

I certify that the statements and answers contained in this application are true and complete to the best of my knowledge and belief. I understand that material misrepresentation or omission of a fact may be the basis for rescission or denial of coverage and may affect coverage for any claim made. I acknowledge that coverage, if issued, will be subject to the terms, conditions, exclusions and limits of the policy.

I authorize Acuity Apps and its authorized representatives to obtain records and information necessary to evaluate this application, including prior insurance and claims history. I understand that submission of this application does not bind coverage until a policy is issued and the required premium is paid.

By signing below the applicant permits the use and disclosure of personal information for underwriting, claims handling, and fraud prevention consistent with applicable law. The applicant understands that additional consents may be required for certain coverages and will be requested if applicable.

Additional Information

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