Insurance Auto Document Template

Insurance Auto Document Template

Applicant / Insured Information

Insured Name:

Date of Birth:   Phone:

Policy Details

Proposed Effective Date:   Policy Term (months):

Policy Number (if renewal):   Producer / Agent:

Coverage Selection

Please select coverages to be included in this policy. Limits and deductibles must be specified where applicable.

Liability Coverage — Limit:

Collision — Deductible:

Comprehensive / Other Than Collision — Deductible:

Medical Payments / Personal Injury Protection — Limit:

Uninsured / Underinsured Motorist — Limit:

Rental Reimbursement — Limit per day:

Roadside Assistance

Vehicle Information (Primary Vehicle)

Vehicle Identification Number (VIN):

Named Drivers

Driver's License Number:   State Issued:

Prior Insurance & Driving History

Prior insurer (last policy):   Policy Number:

Any at-fault accidents or violations in past 5 years? Yes No

Claims and Loss Information

Any claims or losses in the past 5 years? Yes No

Exclusions and Conditions

The policy will contain standard exclusions including, without limitation, loss or liability arising from willful or criminal acts; use of the insured vehicle in racing, speed contests or stunting; operation by a person excluded by endorsement; use of the vehicle for hire as a public conveyance unless specifically endorsed; nuclear hazard, war, government seizure, and wear, tear or mechanical breakdown. Coverage is also subject to policy limits, deductibles, and conditions stated in the declarations and policy form.

The insured must promptly notify the insurer of any material change in risk, including change of principal garaging location, change of ownership, change of primary driver, or new business use of the vehicle.

Beneficiary / Payee Designation (Optional)

For payment of death benefits or personal injury protection where permitted by law, designate recipient below. Primary beneficiary will receive designated percentage of eligible benefits.

Relationship:   Share (%):

Authorization, Certification and Fraud Notice

I certify that the information provided in this application is true, complete and correctly recorded to the best of my knowledge. I understand that this application, any information provided to the insurer, and any applicable driving or claims reports will be relied upon in issuing the policy. I authorize the insurer to obtain motor vehicle records, claims history, and other underwriting information from appropriate sources. Failure to disclose material information or any intentional misrepresentation may result in denial of coverage or rescission of the policy and may subject the applicant to civil or criminal penalties under applicable law.

If false statements or omissions are made with intent to defraud, benefits may be denied and the policy may be voided ab initio. Any payment made in reliance on false information may be recoverable by the insurer.

Sign Now