Insurance Application and Declaration

INSURANCE APPLICATION AND DECLARATION

Application Date:    Producer/Broker Name:

Applicant / Insured Information

Policy Details

Requested Policy Type: Personal Auto    Homeowners    Liability    Life    Health    Commercial    Other:

Policy Period: Effective through

Coverage Options (Select all that apply)

Bodily Injury Liability    Property Damage Liability    Medical Payments    Uninsured/Underinsured Motorist

Comprehensive    Collision    Personal Liability    Replacement Cost Valuation    Actual Cash Value

Exclusions and Limits

The policy to be issued will contain exclusions and limitations customary to the selected coverages. Typical exclusions include but are not limited to:

• Intentional acts, criminal acts, or willful misconduct by the insured;
• Losses arising from declared or undeclared war, insurrection, or nuclear hazard;
• Fraudulent claims or material misrepresentation in the application;
• Normal wear and tear, deterioration, or depreciation; and
• Losses specifically excluded by endorsement in the issued policy.

I acknowledge that I have read and understand the exclusions that may apply and that coverage is subject to policy terms, conditions, limits and deductibles. I acknowledge and accept these exclusions.

Beneficiary Designation

Primary Beneficiary Name:

Contingent Beneficiary Name:

Prior Insurance and Loss History

Have you had any insurance claims in the past five (5) years? Yes    No

Documentation Checklist

Please indicate documents attached with this application:
Proof of Identity (photo ID)    Prior Policy Declarations    Loss Records / Estimates    Photographs of Property / Vehicle    Police Report (if applicable)

Declaration and Applicant Certification

I, the undersigned applicant, declare and certify that the statements made in this application are true, complete and correct to the best of my knowledge and belief. I acknowledge that:

1. All material facts affecting the risk have been disclosed. Failure to disclose a material fact, or making a material misrepresentation, may result in denial of coverage, rescission of the policy, or other legal remedies permitted by law.

2. Coverage under any policy that may be issued is subject to the policy terms, conditions, exclusions, endorsements, limits and deductibles. No coverage is in effect until a policy is issued and the required premium is paid, unless otherwise agreed in writing by the insurer.

3. I authorize the insurer, its agents and representatives to obtain, verify and exchange information, including but not limited to past claims history, loss experience, and other underwriting information from third-party sources and prior insurers for the purposes of underwriting and claims handling. This authorization survives the termination of any resulting policy to the extent permitted by law.

4. I understand premiums are subject to change based on underwriting review, inspection, and verification of the information provided. I agree to notify the insurer promptly of any material changes in the risk described in this application.

5. I certify, under penalty of perjury, that the information provided in this application is true and complete to the best of my knowledge and that I am authorized to provide this information on behalf of any named insured.

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