Insurance Auto Coverage Selection

INSURANCE AUTO COVERAGE SELECTION

Applicant / Insured Information

Policy Details

Policy Number:

Private Passenger Auto
Business Use / Commercial
Fleet / Multiple Vehicles
Non-Owner Liability

Policy Period: From Month: Day: Year:    To Month: Day: Year:

Coverage Selections

The undersigned elects the following coverages and limits. Where limits or deductibles are required, complete the accompanying field. Coverage applies only as provided by the policy terms, conditions, and endorsements.

Bodily Injury Liability Limits:

Property Damage Liability Limit:

Collision Deductible:

Comprehensive Deductible:

Uninsured / Underinsured Motorist Limit:

Medical Payments / Personal Injury Protection Limit:

Rental Reimbursement Limit:

Roadside Assistance / Towing Limit / Notes:

Additional coverages / endorsements requested:

Vehicle Information (Primary Vehicle)

Exclusions and Limitations

The coverages selected are subject to the terms, conditions, exclusions, limitations and endorsements contained in the policy. Typical exclusions include, without limitation: intentional acts of the insured; operation of the insured vehicle for professional racing or speed contests; use of the vehicle for hire where not declared; operation by an unlisted or suspended driver; coverage for wear, tear or mechanical breakdown; punitive or exemplary damages unless covered by law; loss occurring while the vehicle is used in the commission of a felony; and losses arising from non-disclosure or material misrepresentation. Limits of liability and deductibles elected shall apply per the policy declarations. The insured must notify the insurer promptly of changes in vehicle ownership, principal operator, garaging location, or regular use.

By initialing below, the insured acknowledges receipt and review of the exclusions and limitations above and confirms that selections on this form are made knowingly.

Initials:

Additional Interested Parties / Beneficiary

Loss Payee / Additional Insured Name:

Beneficiary for Medical Payments / AD&D (if applicable):

Relationship:    Percentage:

Declaration and Authorization

I certify that the information provided on this Insurance Auto Coverage Selection form is true and complete to the best of my knowledge. I understand that coverage is effective only when accepted and issued by the insurer and that premiums, limits and deductibles shown on this form will be incorporated into the policy declarations. I acknowledge that failure to disclose material information or any material misrepresentation may result in rescission or denial of coverage. I authorize the insurer and its agents to obtain and verify driving records, prior claims history, and other information necessary to underwrite the policy. I agree to comply with the policy terms and to notify the insurer promptly of any material change in the facts provided.

By signing below, I request and authorize issuance of the coverages selected on this form and certify that I have read and accept the exclusions, conditions, and authorizations set forth herein.

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