Insurance Auto Checklist

INSURANCE AUTO CHECKLIST

This Insurance Auto Checklist is an official record of the insured, vehicle, policy and incident documentation relevant to an active automobile insurance policy. Completion and signature certify that the information provided is true, complete and accurate to the best of the applicant's knowledge and that the applicant authorizes verification of the information where permitted by law.

Insured / Applicant Information

Date of Birth:    Phone:    Email:

Vehicle Information

Year:    Make:    Model:

License Plate:    Odometer Reading:    Primary Use:

Ownership Status: Owned Financed/Leased Other

Policy Coverage Details

Policy Type:    Premium Amount:

Liability Limit:    Collision Deductible:    Comprehensive Deductible:

Policy Period Start:    End:

Coverage Checklist (Select all that apply)

Liability    Collision    Comprehensive

Uninsured/Underinsured Motorist    Medical Payments    Rental Reimbursement

Roadside Assistance    Custom Equipment Coverage

Exclusions, Pre-existing Damage & Modifications

The policy excludes loss, liability or expense arising from intentional acts, racing, use of the vehicle for hire where not covered, and losses arising from unreported modifications or non-factory equipment unless specifically endorsed. The insured must disclose all material modifications and pre-existing damage at the time of application or claim.

Incident / Claim Information (if applicable)

Date of Loss:    Time of Loss:

Estimated Damage Amount:    Reported to Police:    Police Report Number:

Documentation Checklist

Photos of damage    Police report    Repair estimate

Receipts    Witness statements    Other (describe below)

Beneficiary for Death Benefit (if applicable)

Relationship:    Allocation Percentage:

Declaration and Certification

I, the undersigned, certify under penalty of perjury (where applicable) that the information provided on this checklist is true and complete. I understand that knowingly providing false information or omitting material information may constitute insurance fraud and may be subject to civil or criminal penalties. I authorize the insurer to obtain and verify information relating to this application and any reported loss, including motor vehicle records, repair estimates, and police reports, to the extent permitted by law.

I acknowledge and certify the foregoing statements.

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