Insurance Auto Documents

AUTO INSURANCE APPLICATION & DECLARATION

Applicant / Insured Information

Date of Birth:   Driver's License #:   State Issued:

Primary Phone:   Email:

Vehicle Information (Primary Vehicle)

Year:   Make:   Model:

Primary Use:   Odometer:

Policy Details & Coverage Selection

Desired Effective Date:   Policy Period From:  To:

Select coverages to be included in the policy (check all that apply):

Liability (Bodily Injury / Property Damage)     Collision     Comprehensive

Uninsured / Underinsured Motorist     Personal Injury Protection (PIP)     Medical Payments

Rental Reimbursement     Roadside Assistance

Coverage Limits, Deductibles & Premium

Liability Limit (per person / per accident):   Property Damage Limit:

Comprehensive Deductible:   Collision Deductible:

Estimated Annual Premium:   Estimated Monthly Payment:

Exclusions & Limitations

The insurance provided under this application is subject to the terms, conditions and exclusions contained in the policy. Common exclusions include but are not limited to:

• Loss caused intentionally by the insured or while committing a criminal act;
• Use of the vehicle for commercial hire, livery services, or delivery for compensation unless specifically endorsed;
• Damage resulting from wear and tear, mechanical breakdown, or gradual deterioration;
• Use of the vehicle by an unlicensed driver, or by a driver excluded on the policy;
• War, nuclear hazard, and governmental seizure as provided in the policy.

I acknowledge that I have read the exclusions above and understand that additional exclusions and conditions appear in the policy form. Initial to acknowledge:

Beneficiary Designation (PIP / Death Benefits)

Designate primary beneficiary(s) for personal injury protection death benefits if applicable.

Relationship:   Share Percentage:

Claims History & Disclosures

In the past five (5) years, have you had any motor vehicle accidents or insurance claims?   Yes   No

Any motor vehicle convictions (DUI, reckless driving, excessive speed) in past five (5) years?   Yes   No

Documentation Checklist

Please attach or provide the following documentation as applicable (check items provided):

Copy of driver's license

Vehicle registration

Proof of prior insurance (declaration page)

Photos of vehicle damage (if applicable)

Declaration and Certification

I certify that the information provided in this application is true, complete and correct to the best of my knowledge and belief. I understand that any material misrepresentation, omission, or incorrect statement in this application may be grounds for denial of coverage or rescission of the policy in accordance with the terms of the policy and applicable law.

I authorize the insurer, its agents and representatives to obtain and verify motor vehicle records, claims history, driving record, credit information and other underwriting information necessary to evaluate this application and any future renewal or claim. I further authorize release of information to my listed lienholder or loss payee when such interest is recorded on the policy.

I understand premiums are based on the information provided and that coverage will not be effective until accepted by the insurer and any required premium payment is received. Coverage is subject to the terms, conditions, endorsements and exclusions of the policy issued. I acknowledge receipt of any required fraud warnings and understand that false statements may be punishable by civil or criminal penalties.

Additional Remarks

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