Insurance Application Mapfre

Insurance Application — MAPFRE

Applicant / Insured Information

Applicant Name:

Date of Birth:    Social Security/Tax ID:

Policy Details

Requested Policy Type: Property Auto Liability Other

Policy Period From:    To:

Coverage Options

Please indicate desired coverages (check all that apply):

Property Damage
General Liability
Collision
Comprehensive
Medical Payments
Uninsured/Underinsured Motorist
Additional Endorsement (specify below)

Exclusions and Limitations

The following are examples of standard exclusions under this application unless otherwise agreed in writing: intentional acts, wear and tear, losses arising from war or nuclear hazard, losses from illegal activity, and losses excluded by endorsement. This application does not bind coverage. Any coverage issued will be subject to the policy terms, conditions, limitations and exclusions.

Applicant acknowledges review of typical exclusions and agrees that additional exclusions may apply. Applicant affirms that no material facts have been omitted that would affect underwriting of the requested coverage.

Applicant Acknowledgement: I acknowledge and accept the stated exclusions and limitations.

Beneficiary Designation

Claims and Loss History

Have you had any claims, losses or liability incidents in the past 5 years? Yes No

Underwriting Questions

Has any insurer cancelled or refused to renew your insurance within the past five years? Yes No

Do you or any proposed insured engage in high-risk activities or occupations (e.g., demolition, aviation, marine operations)? Yes No

Documentation Checklist

Please provide or confirm applicable documents (check those included):

Government issued photo ID
Proof of address (utility bill)
Vehicle title / registration (auto policies)
Photos of property to be insured
Prior policy declarations (if available)

Declaration, Authorization and Certification

By signing this application the Applicant certifies that the information set forth in this application is true, complete and correct to the best of Applicant's knowledge. Applicant understands that this application forms the basis of any policy issued and that material misstatement, omission, or concealment of fact may permit MAPFRE to void coverage for the affected risk and to deny claims arising therefrom.

Applicant authorizes MAPFRE and its representatives to obtain and verify information, including underwriting and claims history from insurers, consumer reporting agencies, and other third parties as reasonably necessary for underwriting, risk assessment and claims handling. Applicant permits release of claim and underwriting information to reinsurers as required. Applicant further authorizes any person or entity to provide such information.

Fraud Warning: Any person who knowingly presents false or fraudulent information for the purpose of obtaining insurance may be subject to criminal and civil penalties, and coverage may be rescinded or claims denied.

I acknowledge that completion of this application does not guarantee issuance of a policy. Coverage, limits, endorsements, and conditions will be set forth in the policy document delivered by MAPFRE and are subject to underwriting approval and payment of premium.

Applicant Authorization: I hereby authorize the disclosures and representations set forth above.

Additional Remarks

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