Insurance Application Signature Pages

INSURANCE APPLICATION SIGNATURE PAGES

Applicant / Insured Information

Date of Birth:

Policy Details

Selected Coverages

Bodily Injury & Property Damage Liability

Collision   Limit:

Comprehensive   Deductible:

Medical Payments / Personal Injury Protection

Uninsured / Underinsured Motorist

Exclusions and Limitations

The following exclusions and limitations apply to the coverages selected. The insurer will not provide coverage for losses arising directly or indirectly from the items listed below unless specifically endorsed:

Beneficiary Designation

Declarations, Authorizations and Acknowledgements

I certify that the information provided in this application and any attachments is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation or omission may be the basis for denial of coverage, cancellation of the policy, or rescission of coverage as permitted by law.

I authorize the insurer and its representatives to obtain and verify information from third parties, including but not limited to medical providers, prior insurers, motor vehicle records, and other relevant sources, for the purpose of underwriting, rating, claims handling and fraud investigation. I further authorize those third parties to release such information to the insurer upon request.

I acknowledge receipt of the required disclosures and notice of consumer rights where applicable. I understand that coverage will not be effective until accepted by the insurer and any required premium is paid, subject to all terms, conditions and exclusions of the policy.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim or statement for payment of a loss is subject to criminal and civil penalties under applicable law. I understand that the insurer will investigate suspected fraud and may share information with law enforcement or applicable regulatory authorities.

Consent to Electronic Delivery: By signing below I consent to receive policy documents, notices and communications electronically unless I expressly revoke this consent in writing.

Certification and Signature

By signing below, I acknowledge that I have read and understood all statements, representations and authorizations contained on these signature pages and in the associated application. I agree that this signed document is a material part of the application for the policy and that any false statement or omission may be grounds for denial of coverage or rescission as permitted by law.

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