Insurance Auto Home Application

INSURANCE AUTO HOME APPLICATION

Applicant / Insured Information

Owner Renter Secondary/Seasonal

Policy Details

Policy Type: Auto Home Combined Auto/Home

Vehicle Information (List each vehicle to be insured)

Vehicle 1

(Add additional vehicles as necessary on a separate form or attachment)

Driver Information

Primary Driver

None Yes — If yes, provide details below

Property / Home Information

Amenities and Features: Swimming Pool Security System Fire/Smoke Alarm

Coverages Requested

Auto Coverages

Liability Limit: Collision Deductible:

Comprehensive Deductible: Uninsured / Underinsured Motorist Limit:

Medical Payments Limit: Roadside Assistance

Home Coverages

Dwelling Coverage (Coverage A) Limit:

Other Structures (Coverage B) Limit: Personal Property (Coverage C) Limit:

Loss of Use (Coverage D) Personal Liability (Coverage E) Limit:

Prior Insurance & Loss History

Beneficiary / Loss Payee

Designate beneficiary or payee for claim proceeds or mortgagee notifications:

Documentation Checklist

Please indicate which of the following are provided with this application:

Driver's license copy Vehicle registration Property photos Prior policy declarations

Exclusions, Limitations and Important Notices

The coverage applied for does not apply to losses resulting from: intentional acts; wear, tear or gradual deterioration; acts of war; nuclear hazard; punitive damages except where required by law; theft or loss related to business use not disclosed to the insurer; and perils specifically excluded by endorsements (including flood and earthquake unless specifically endorsed). Insurance issued pursuant to this application is subject to the terms, conditions, exclusions and limitations contained in the policy and any endorsements. Coverage limits, deductibles and conditions provided above are applicant requests and will be subject to underwriting approval and the final policy language.

Applicant acknowledges that additional endorsements may be required to provide coverage for certain perils and that separate policies may be recommended for flood, earthquake, or specialized business property.

Applicant acknowledges review of exclusions and limitations above and understands that issuance of a policy is subject to underwriting and acceptance.

Declarations, Authorization and Certification

By signing below, I certify that the information in this application is true and complete to the best of my knowledge and belief. I understand that any material misrepresentation, omission, or fraudulent statement made in connection with this application may be grounds for denial of coverage, rescission of any resultant policy, or criminal prosecution where applicable.

I authorize the insurer and its representatives to obtain and verify motor vehicle records, claim history, credit information, and other relevant consumer reports for underwriting, rating and claims handling purposes. I authorize the release of information concerning my insurance claim history to other insurers or their agents as permitted by law. I understand that underwriting acceptance and premium are subject to verification of facts supplied, inspection of vehicles or property and receipt of required documentation.

I agree to notify the insurer of any material changes to the information provided that occur prior to the effective date of coverage. I acknowledge that coverage is not bound until confirmed in writing by an authorized representative of the insurer and that any binder issued is subject to the insurer's terms and underwriting standards.

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