Insurance Application Geico

INSURANCE APPLICATION — GEICO

Applicant / Insured Information

Date of Birth:    Social Security Number:

Primary Phone:    Email:

Policy Details

Desired Policy Type(s):

Auto    Motorcycle    Homeowners    Renters    Umbrella/Liability

Coverage Limits / Options:

Liability Bodily Injury per person: $    Liability Bodily Injury per accident: $

Property Damage Liability: $    Comprehensive Deductible: $    Collision Deductible: $

Vehicle Information (if applicable)

Driving History

Number of at-fault accidents in last 5 years:

Any moving violations, DUI, or license suspensions in last 5 years?   Yes   No

Coverage Selection

Select optional coverages requested:

Collision Deductible Waiver    Rental Reimbursement    Roadside Assistance    Medical Payments

Exclusions and Important Notices

The policy applied for will not provide coverage for losses arising from intentional acts; operation of the insured vehicle for hire (unless specifically endorsed); use of the vehicle in a contest or speed test; racing; war or nuclear incidents; or any use prohibited by law or by the policy. Additional exclusions and limitations may apply as set forth in the policy contract.

By checking the box below the applicant acknowledges receipt of, and understands, these exclusions and that no coverage is binding until a policy is issued and the first premium is paid or coverage is otherwise confirmed in writing by the insurer's authorized representative.

Applicant acknowledges and understands exclusions and limitations stated above.

Beneficiary Designation (if applicable)

Beneficiary Name:

Relationship:    Percentage of proceeds:

Alternate Beneficiary (optional):

Declarations and Applicant Certification

I, the undersigned applicant, declare that the information contained in this application is true, correct and complete to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage, cancellation of coverage, or rescission of the policy. I warrant that the answers and statements made herein are offered to the insurer as an inducement to issue the policy applied for.

I authorize the insurer and its agents to obtain motor vehicle records, claims history, credit information, and other consumer reports as permitted by applicable law for underwriting, premium determination, and claims handling. I further authorize employers, schools, licensing authorities, and other insurers to release to the insurer any information they may have concerning me or any driver listed on this application.

Fraud Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false information may be guilty of insurance fraud under applicable law and subject to criminal and civil penalties.

Certification: By signing below I certify under penalty of perjury that the foregoing statements, answers and information are true and complete. I understand that coverage, if offered, shall be governed by the policy terms, conditions and exclusions contained in the issued policy document.

I certify that the information provided in this application is complete and accurate.

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