Insurance Application & Required Documents

Insurance Application & Required Documents

Applicant / Insured Information

Date of birth:    Social Security No. (last 4 digits):

Policy Details

Policy type (select all that apply):
Homeowners / Dwelling   Automobile   Renters   General Liability

Requested policy period start:    end:

Coverages Selected

Indicate coverages to be included (check and provide limits where required):
Bodily injury & property damage liability
Comprehensive
Collision
Uninsured/Underinsured motorist
Personal property coverage

Exclusions and Special Conditions

The following are typical exclusions that may apply unless specifically endorsed: war or acts of foreign enemies; nuclear hazard; intentional loss; wear and tear, gradual deterioration; loss due to fraud or criminal conduct by the insured; certain water damage and mold losses unless specifically included in the policy. Presence of an exclusion does not alter the insurer's right to nonrenewal or cancellation under policy terms.

Applicant acknowledges receipt and review of exclusions and special conditions and understands that coverages are subject to policy terms, conditions and exclusions. Acknowledged:

Beneficiary / Loss Payee Information

Prior Insurance & Claims History

Have you had any claims in the last 5 years? Yes   No

Required Documents Checklist

The following documents must accompany this application. Check the boxes when attached and upload when available.

Government‑issued photo ID attached

Proof of address (utility bill, lease) attached

Prior policy declarations or loss runs attached

Inspection photos or evidence (if applicable)

Signed authorization to obtain records

Declarations, Representations & Authorizations

I, the undersigned applicant, declare that the information provided in this application and in any supporting documents is true, complete and correct to the best of my knowledge. I understand that intentional misrepresentation, omission or concealment of a material fact in this application or in connection with any claim may be grounds for denial of coverage, rescission of the policy, or criminal prosecution to the extent permitted by law.

I authorize the insurer and its agents to obtain and verify information concerning my insurance claims history, credit information where permitted by law, and any other information relevant to underwriting and administration of the policy. I further authorize providers, prior insurers, employers and other entities to disclose such information to the insurer and its representatives.

I understand that coverage will not be effective until accepted and issued by the insurer and any required premium has been paid in accordance with policy terms. I agree to promptly notify the insurer of any material changes in the facts set forth in this application prior to inception of coverage.

Fraud Warning / Privacy Notice

Any person who knowingly submits false information or omits material information with intent to defraud may be guilty of insurance fraud. Personal information provided on this application will be used to process the application, administer the policy, and for other lawful business purposes. The insurer will handle personal data in accordance with applicable law.

Additional Information

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