Insurance Auto Application

INSURANCE AUTO APPLICATION

Applicant / Insured Information

Vehicle Information

Drivers to be Insured

Primary Driver: Relationship:

Driver's DOB: License State:

Requested Policy Information

Requested Policy Type: Liability Collision Comprehensive Uninsured/Underinsured Motorist

Requested Policy Period: From to

Coverages & Endorsements

Select additional coverages requested (check all that apply):

Gap Insurance Rental Reimbursement Roadside Assistance Medical Payments

Exclusions, Notices and Important Information

The policy applied for will contain exclusions, conditions and limitations including but not limited to: intentional acts, use of vehicle for livery or public hire unless specifically endorsed, operation by an excluded driver, unreported modifications that affect risk, and use of a vehicle in the commission of a felony. Coverage is subject to all policy terms, conditions, limitations and exclusions in the issued policy.

Applicant affirms that all statements made in this application are true and complete to the best of the applicant's knowledge. Material misrepresentation, omission or concealment of facts may result in denial of coverage, rescission of the policy, or adjustment of premiums and benefits.

Claims & Loss History

No Yes — If yes, provide details below

Documentation Checklist

Please indicate documents attached with this application:

Copy of Driver's License Vehicle Registration Prior Policy Declarations Photos of Vehicle (if damage)

Beneficiary for Medical/Death Benefits (if applicable)

Beneficiary Name: Relationship:

Beneficiary Percentage:

Declaration and Certification

I certify under penalty of perjury that the statements contained in this Application are true and complete. I authorize the insurer and its authorized representatives to obtain motor vehicle reports, claim and loss history, credit information where permitted by law, and to verify any information provided herein. I understand that coverage will not be effective until the application is accepted and a policy is issued in accordance with the insurer's underwriting rules and subject to payment of required premium.

I further acknowledge that intentionally providing false information or failing to disclose material facts may be grounds for denial of claims or rescission of coverage. I agree to notify the insurer of any material change in the information provided in this application that occurs prior to the effective date of the policy.

Authorization for Electronic Delivery and Signature

By signing below I consent to receive policy documents, notices and billing statements in electronic form where permitted by law. I agree that an electronic signature applied to this application has the same force and effect as an original handwritten signature.

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