Insurance Auto Application and LPR

Insurance Auto Application and LPR

Applicant / Insured Information

Date of birth:    Driver's license #:    State:

Phone:    Email:

Vehicle Information

Year:    Make:    Model:    Body type:

Purchase date:    Purchase price:

Ownership status:    Owned    Financed    Leased

Policy Details and Coverages Requested

Desired effective date:    Policy period start:    Policy period end:

Coverage selections (check all that apply):
Liability    Collision    Comprehensive    Uninsured/Underinsured Motorist    Medical Payments    Roadside Assistance

Estimated annual premium:    Payment frequency:

Coverage Options — Additional Drivers

DOB:    DL #:

DOB:    DL #:

Claims History and Losses

Have you had any accidents or insurance claims in the past 5 years?    Yes    No

Beneficiary / Designated Payee

If applicable for medical payments or death benefits, provide beneficiary designation below.

Lienholder / Loss Payable Recipient (LPR)

Complete this section to identify the lender, lienholder, or loss payee to be named on the policy.

LPR account/loan number:    Phone:    Email:

Request to list LPR as loss payee/lienholder: I request the insurer to list the above-named LPR as loss payee or lienholder for payments for physical damage, subject to policy terms.

If a loss payment is made for physical damage to the described vehicle, any payment will be made payable to the insured and the LPR as their interests may appear, as set forth by policy provisions and applicable law. The insurer is authorized to furnish to the LPR copies of policy changes, cancellation notices, and proof of insurance to protect the LPR's interest.

Exclusions and Important Notices

The policy will not cover loss or liability arising from intentionally caused events, operation by a person under the influence of alcohol or controlled substances, use of the vehicle in the commission of a crime, professional racing, wear and tear or mechanical breakdown, or use of the vehicle for commercial transport of goods for hire unless specifically endorsed. Additional exclusions may apply as stated in the policy.

Applicant acknowledges that material misrepresentation or omission of relevant facts may result in denial of coverage, rescission of the policy, or adjustment of claim payments. False statements made to obtain insurance benefits may be subject to civil or criminal penalties under applicable law.

Declarations, Authorizations & Certification

By signing this application the undersigned declares that all statements made in this application are accurate and complete to the best of their knowledge. The undersigned understands that the insurer will rely upon these statements in determining insurability and premium and that any material misstatement or omission may render the policy void from inception.

The applicant authorizes the insurer and its agents to obtain motor vehicle records, claims history, credit history where permitted by law, and other underwriting information as necessary to evaluate this application and service any resulting policy. The applicant consents to release of underwriting and claims information to the named LPR to protect the LPR's interest.

Acknowledgment: I acknowledge that knowingly providing false information in order to procure insurance or to obtain payment of a claim is a fraudulent act and may be subject to prosecution under applicable law.

I certify that the information provided in this application and any attachments is true and complete. I understand that signing this application does not in itself bind coverage. Coverage is effective only if the insurer accepts this application and any required premium payment is received and processed.

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