Insurance Application Package

INSURANCE APPLICATION PACKAGE

Applicant / Insured Information

Policy Details (Requested)

Select policy type(s) applying for:
Homeowners   Dwelling Fire   Automobile   Renters   Umbrella / Excess Liability   Life (term / whole)

Coverage Options

Select coverages requested (limits to be determined by underwriter):
Dwelling / Building Coverage
Personal Property
Personal Liability
Loss of Use / Additional Living Expense
Medical Payments
Collision (auto)
Comprehensive (auto)
Uninsured / Underinsured Motorist
Personal Injury Protection

Exclusions & Acknowledgments

The undersigned acknowledges that the policy applied for will contain standard industry exclusions, including but not limited to: acts of war, intentional acts or illegal activity by the insured, wear and tear, and losses excluded by endorsement. The applicant understands that specific exclusions will be set forth in the policy and endorsements issued.

Beneficiary Designation (Life Coverage Only)

To designate a beneficiary for any life insurance applied for, complete the following. If no beneficiary is designated, proceeds will be payable according to the policy terms and applicable law.

Prior Insurance & Claims History

Have you had any losses or claims in the past five years? Yes No

Documentation Checklist

Include the following documents with this application (check submitted items):

Declarations, Authorizations & Fraud Warning

I declare that the information contained in this application is true and complete to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact in this application may result in denial of coverage or rescission of the policy. I authorize the insurer, its representatives and any insurance-support organizations to obtain and share consumer reports, claim history, credit information and other underwriting data necessary to evaluate eligibility, rates and coverage. Such information may be retained by the insurer and used to administer any policy issued.

I understand that coverage will not be effective until approved by the insurer and, if required, until the first premium is received and accepted. I agree to pay premiums in accordance with the policy terms. I authorize release of information to mortgagees, lienholders, and third parties as required by the policy or law.

Agent / Producer Information (If applicable)

Certification & Signature

By signing below I certify under penalty of perjury that the foregoing statements are true and complete. I acknowledge that false statements or omissions may be punishable by civil or criminal penalties and may void coverage. I further authorize the insurer to verify any information provided in this application and to obtain pertinent records for underwriting and claims handling.

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