Insurance Auto Application Form

INSURANCE AUTO APPLICATION FORM

Applicant / Insured Information

Applicant Name:

Date of Birth:   Driver's License No.:   State Issued:

Vehicle Information

Year:   Make:   Model:

Primary Use:   Annual Mileage:

Drivers to be Insured (List all household drivers)

Coverage Requested

Select coverages to be applied for. Availability and limits subject to underwriting approval.

Liability Limits: Bodily Injury per person / per accident and Property Damage

Collision Coverage — Deductible:

Comprehensive Coverage — Deductible:

Uninsured/Underinsured Motorist — Limits:

Medical Payments — Limit:

From:   To:

Premium / Payment

Payment Method Preference: Full Pay Installments Automatic Bank/Card Draft

Prior Insurance and Claims History

Have you had prior automobile insurance in the past 36 months?   Yes No

Policy Period: From To

Exclusions and Important Notices

The policy applied for will contain exclusions, conditions and limitations. Common exclusions include intentional acts, use of the vehicle for livery or delivery where not declared, and operation by excluded drivers. Coverage is subject to the policy terms, conditions, endorsements and applicable limits. The insurer reserves the right to decline coverage or impose underwriting restrictions based on driving record, VIN history, vehicle modifications, or other underwriting criteria.

Beneficiary Designation (for return of unearned premium, if applicable)

Beneficiary Name:

Relationship:   Share Percentage:

Declarations, Authorization and Certification

I certify that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may result in denial of coverage, rescission of the policy, or other remedies permitted by law and by the policy terms.

I authorize the insurer and its representatives to obtain motor vehicle records, claims history, credit information where permitted by applicable law, and any other information reasonably necessary to evaluate this application and service the policy. This authorization extends to consumer reporting agencies, prior insurers, motor vehicle departments, and claim reporting databases. I understand that a copy of this authorization is as valid as the original.

I acknowledge that coverage is not effective until accepted by the insurer and a policy or binder is issued. Any binder issued is subject to the insurer's underwriting terms and may be voided if material facts are later found to be inaccurate or incomplete.

Electronic Communications Consent: I consent to receive policy documents, notices and billing electronically where permitted. I decline electronic delivery and request paper communications.

Applicant Certification

By signing below I affirm under penalty of perjury that I am the person named above and that the statements in this application are true and complete. I understand that signatures provided electronically are legally binding to the same extent as a handwritten signature.

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