Insurance Application Request

INSURANCE APPLICATION REQUEST

Applicant / Insured Information

Date of birth:   SSN / Tax ID:

Phone:   Email:

Policy Details Requested

Policy type (select all that apply): Auto Homeowners Renters Life Commercial Other:

Requested deductible:   Estimated annual premium:

Policy period requested: From to . Preferred effective date:

Coverages & Limits

Select coverages requested: Liability Collision Comprehensive Medical Payments

Exclusions, Prior Coverage & Loss History

By submitting this request the Applicant acknowledges that standard policy exclusions apply, including but not limited to intentional acts, willful misconduct, pollution where excluded, wear and tear, and loss arising from criminal activity. Coverage is subject to underwriting and the final policy contract.

Prior policy period: From to . Policy number:

Any claims, losses or incidents in the past five (5) years? Yes No

Beneficiary Designation

Primary beneficiary 1:

Additional beneficiaries may be listed on an attached schedule and will be considered part of this application when signed by the Applicant and accepted by the Company.

Documentation Checklist

Government‑issued photo ID Proof of address (utility bill, lease) Prior policy declarations / loss history Photographs or inspection reports (if applicable) Medical records / exam (life applications only)

Declarations, Authorizations & Warnings

The Applicant certifies that the information provided in this application is true, complete and correct to the best of the Applicant's knowledge. The Applicant understands that any material misrepresentation, omission, or concealment may result in denial of coverage, rescission of the policy, or claim denial.

By signing below the Applicant authorizes the insurer, its agents, representatives and reinsurers to obtain and verify underwriting information, which may include motor vehicle records, credit information, prior loss history, claims databases and medical or employment records where relevant to the risk. The Applicant further authorizes third parties to release such information to the insurer and its reinsurers.

The Applicant acknowledges that coverage, if issued, will be subject to policy terms, conditions, limitations and exclusions set forth in the final policy. Premiums quoted herein are estimates and are subject to change upon underwriting review. No coverage is in effect until the insurer issues a policy or a binder is delivered and any required premium is paid.

Fraud Warning: Where permitted by law, it is unlawful to knowingly submit false information for the purpose of obtaining insurance. Such acts may constitute insurance fraud and may be subject to civil and criminal penalties under applicable law.

Applicant Certification

I hereby declare that I have read and understand the statements contained in this Application Request. I affirm that the information provided in this form is accurate and complete. I authorize the insurer to rely upon this information in evaluating this request for insurance. I agree to notify the insurer of any material change in the information provided prior to issuance of a policy.

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