Insurance Application PDF

INSURANCE APPLICATION

Applicant / Insured Information

Applicant Name:

Phone:    Email:

Date of Birth:    Social Security Number / Tax ID:

Policy Details

Desired Effective Date:    Desired Term End Date:

Coverage Limit Requested: $    Deductible: $    Estimated Annual Premium: $

Coverage Options & Selections

General Liability    Limit: $

Property Damage / Property Insurance    Limit: $

Collision / Physical Damage    Deductible: $

Medical Payments    Limit per person: $

Uninsured / Underinsured Motorist    Limit: $

Exclusions and Limitations

The applicant acknowledges that standard policy exclusions and limitations apply, including but not limited to losses arising from intentional acts, known prior loss, war, nuclear hazard, and criminal activity. Any additional exclusions specific to the requested policy type will be set forth in the policy form and endorsements issued if coverage is bound.

Beneficiary / Loss Payee Information

Beneficiary / Payee Name:

Relationship to Applicant:    Allocation Percentage:

Prior Insurance & Loss History

Have you had any claims, losses or accidents within the last 5 years?   Yes    No

Documentation Checklist

Copy of Driver's License    Photographs of Insured Property/Vehicle

Prior Policy Declarations    Loss Reports (if applicable)

Declarations, Authorizations and Certifications

I, the undersigned Applicant, declare that the foregoing statements and answers are true, complete, and correctly recorded to the best of my knowledge. I understand that any material misstatement or omission may give rise to denial of coverage or rescission of the policy and may constitute insurance fraud.

I authorize the insurer and its representatives to make any inquiries, investigations, or inspections they consider necessary in connection with this application, including obtaining claim history, credit information, and other relevant records. I consent to release of such information to the insurer and its reinsurers for underwriting and claims handling purposes.

I agree that coverage, if issued, will be subject to the terms, conditions, limitations, and exclusions of the policy form and any endorsements issued. Premiums are due in accordance with the policy and may be subject to down payment, installment plan, or audit adjustment. I understand that coverage is not effective until the insurer issues a policy or binder and receives any required premium or deposit, unless otherwise agreed in writing.

Fraud Warning: Any person who knowingly and with intent to defraud submits an application containing false, incomplete, or misleading information may be subject to civil or criminal penalties, denial of claims, and termination of coverage.

I certify that all statements on this application are true and complete.    I authorize investigation and verification of the information provided.

I consent to receive policy documents, notices and billing electronically where permitted by law.

Additional Information / Remarks

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