Insurance Application Safeco

INSURANCE APPLICATION SAFECO

Applicant / Insured Information

Policy Details

Homeowner    Auto    Renters    Umbrella/Excess    Commercial Property/Liability

Proposed Policy Period: From to

Coverage Options & Endorsements

Select desired coverages and indicate optional limits where applicable.

Property (buildings, contents)    Personal Liability    Automobile Liability    Medical Payments

Water Backup Coverage    Identity Theft Expense    Business Pursuits Endorsement

Prior Insurance / Loss History

Have you had any claims, losses, or policy cancellations in the last five years?    Yes    No

Exclusions and Important Notices

The proposed policy will exclude loss or liability arising from: (a) intentional acts or criminal conduct by the insured; (b) war, sabotage, or nuclear hazard; (c) wear, tear, deterioration, inherent vice or latent defect; (d) pollution and contamination unless specifically endorsed; (e) contractual liability assumed by the insured except to the extent such liability would have attached in the absence of the contract. Additional exclusions may apply pursuant to policy language and endorsements issued at inception.

Applicant acknowledges that issuance of a policy is subject to underwriting review, verification of all information provided, and receipt of premium. Coverage is not effective until a policy is issued and premium is received or a binder is issued in accordance with underwriting authority.

Beneficiary Designation (if applicable)

Declarations, Authorization and Certification

By signing below, the applicant certifies that all statements made in this application are true and complete to the best of the applicant's knowledge and belief. Applicant understands that any material misstatement, omission, or concealment of fact may result in declination of coverage, rescission of the policy, reduction in benefits, or denial of claims. Applicant authorizes the insurer to obtain, verify and exchange underwriting, claims and credit information as reasonably necessary for underwriting and administering the policy, including with reinsurers, administrators and service providers.

Applicant further acknowledges that submission of this application does not bind the insurer to issue coverage. Coverage, if issued, will be governed by the terms, conditions and exclusions of the policy and any endorsements issued thereunder. Applicant agrees to promptly notify the insurer of any material change in circumstances prior to the effective date of coverage.

Fraud Warning: Any person who knowingly provides false, incomplete, or misleading information for the purpose of defrauding an insurer may be subject to civil and criminal penalties under applicable law, including denial of benefits and prosecution.

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