Insurance Application for Signature

INSURANCE APPLICATION FOR SIGNATURE

Applicant / Insured Information

Applicant Name:

Date of Birth: Month Day Year

Phone:    Email:

Policy Details

Requested Policy Type:

Homeowners    Auto    Renters    Personal Liability

Desired Coverage Amount: $    Deductible: $

Policy Period From: Month Day Year

To: Month Day Year

Coverage Options (select applicable)

Property Damage
Personal Liability
Medical Payments
Theft Coverage
Flood (optional)
Earthquake (optional)

Exclusions and Acknowledgements

Standard exclusions include but are not limited to: loss intentionally caused by the insured; wear and tear; damage from hostile or war-like action; pollution or contamination except where specifically endorsed; failure to maintain property; losses arising from criminal activity by the insured. Coverage for flood, earthquake and certain named perils requires separate endorsement and premium.

I acknowledge that I have read and understand the exclusions set forth above. Initials:

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Share (%):

Relationship:    Share (%):

Prior Insurance / Loss History

Any claims or losses in the last 5 years? Yes    No

Declarations and Authorizations

By signing below, I declare under penalty of perjury that the foregoing statements and answers are true and complete to the best of my knowledge. I understand that any material misrepresentation or omission may render coverage void or permit rescission of the policy from inception. I acknowledge that premiums, endorsements, and policy terms are subject to underwriting review and that issuance of a binder or policy is subject to approval by the insurer.

I authorize the insurer and its representatives to obtain and verify information concerning my insurability, including previous insurance and claims history, and to share relevant information with other insurers and persons with a legitimate business need, in accordance with applicable law. I consent to inspections of insured property and to additional inquiry into facts material to this application.

I understand any coverage provided prior to full underwriting acceptance may be limited and subject to conditions, and that payment of the premium does not guarantee issuance of a policy where material misstatements are discovered.

Applicant Certification: I certify that I have disclosed all material facts known to me that are relevant to the underwriting of this application. I understand that this application becomes part of the policy and that false statements may constitute insurance fraud under applicable law.

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