Insurance Application Grange

Insurance Application Grange

Applicant / Insured Information

Applicant Name:

Telephone:    Email:

Date of Birth: Month Day Year

Policy Details

Policy Type: Property Liability Auto Farm / Agricultural Other

Desired Deductible:    Estimated Annual Premium:

Policy Period: From Month Day Year   To Month Day Year

Coverages Requested

Select requested coverages and indicate limit(s) where applicable:

Property Damage — Limit:

Liability — Each Occurrence Limit:

Automobile — Vehicle Details:

Commercial / Business Property — Describe:

Exclusions and Notices

The policy applied for will contain exclusions including, but not limited to, losses resulting from: intentional acts, war, nuclear hazard, pollution unless specifically endorsed, wear and tear, and losses excluded by statute. Applicant should review the policy language for complete exclusions. Applicant acknowledges receipt and understanding of the typical exclusions by checking the box:

I acknowledge the exclusions described above and understand these may apply to the policy applied for.

Prior Insurance and Loss History

Have you had any insurance declined, cancelled, or non-renewed in the last five years? Yes No

Beneficiary Designation (if applicable)

Authorization and Declarations

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any material misrepresentation, omission, or incorrect statement may be grounds for denial of coverage or rescission of the policy. I authorize the Company and its agents to obtain underwriting information, loss history, and other consumer reports as necessary to evaluate this application.

I understand premiums quoted are estimates and subject to audit and adjustment based on information verified by the Company. Coverage will be effective only upon issuance of a policy and acceptance of the premium by the Company.

By signing below, I declare under penalty of perjury that the statements in this application are true and complete.

Applicant Authorization to Share Information: I consent to the release of information necessary for the processing of this application and administration of any policy issued.

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