Insurance Auto Application Requirements

Insurance Auto Application Requirements

The Applicant must complete all sections below and provide the documentation checklist items. Incomplete responses or missing documentation may delay underwriting or result in declination. Applicant certifies that all information provided is true and complete to the best of their knowledge and consent is given for the insurer and its representatives to obtain motor vehicle records and related information for underwriting and claims purposes.

Applicant / Insured Information

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

Vehicle Information

Make:    Model:    Year:

Primary Use:    Estimated Annual Mileage:

Drivers to be Insured (Household)

Driver 1 - Name:    DOB:    License No.:

Driver 2 - Name:    DOB:    License No.:

Add additional drivers on a separate sheet if needed. Relationship to applicant (for each):

Policy Details

Policy Period From:    To:

Coverages (select requested coverages)

Liability (Bodily Injury / Property Damage)
Collision
Comprehensive / Other Than Collision
Uninsured / Underinsured Motorist
Medical Payments / Personal Injury Protection
Roadside Assistance / Towing
Rental Reimbursement

Exclusions & Acknowledgements

The following are standard policy exclusions. Applicant acknowledges reading and understanding each exclusion below by checking the corresponding box where indicated.

Damage intentionally caused by an insured or at the direction of an insured is excluded.
Use of the vehicle without the owner’s permission or outside the permitted use stated on the policy may be excluded.
Losses arising from racing or speed contests are excluded.
Loss from war, insurrection, or nuclear hazard is excluded as permitted by law.

Claims / Loss History

In the past five (5) years, has any proposed insured been involved in an accident or had an auto insurance claim?   Yes    No

Beneficiary Designation (If Applicable)

Designate beneficiary for Personal Injury Protection death benefits or similar coverages, if applicable.

Relationship:    Allocation Percentage:

Required Documentation Checklist

Applicant must provide the following items with this application. Check each item provided.

Copy of Driver's License for each operator listed
Vehicle Registration or Title
Prior Carrier Declarations Page (if available)
Photos of vehicle (front, rear, VIN plate)
Other supporting documentation (list below)

Declarations and Certification

I, the undersigned applicant, declare under penalty of perjury that the information contained in this application is true, complete and accurate. I understand that any material misrepresentation or omission may be grounds for denial of coverage, rescission of the policy, or denial of claims. I authorize the insurer to obtain motor vehicle records, claims history, and other underwriting information, and to release information to reinsurance and investigative entities as necessary for underwriting and claims handling.

I acknowledge receipt of and understand the fraud notice applicable in my jurisdiction and understand that knowingly providing false information may constitute insurance fraud under applicable law.

Supplemental Information

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