Insurance Auto Home Application Form

Insurance Auto Home Application Form

Applicant / Insured Information

Date of Birth:

Policy Details

Policy Type: Auto Home Combined Auto-Home

Policy Period: From to

Vehicle Information (If applying for Auto Coverage)

Number of vehicles to insure:

Property / Home Information (If applying for Home Coverage)

Safety / Protections: Smoke alarms Burglar alarm Fire sprinklers

Does the property have a swimming pool or trampoline? Yes No

Coverage Selection and Limits

Auto Coverages (select desired):

Bodily Injury & Property Damage Liability
Limits (per person / per occurrence):

Collision Deductible:

Comprehensive Deductible:

Uninsured/Underinsured Motorist Limits:

Home Coverages (select desired):

Dwelling Coverage (Coverage A) Amount:

Personal Property (Coverage C) Amount:

Personal Liability Limit:

Deductible:

Exclusions and Acknowledgements

The policy will contain standard exclusions, including but not limited to: intentional acts, loss due to war or nuclear hazard, wear and tear, and loss resulting from failure to perform reasonable maintenance. Coverage for flood, earthquake, mold, or other specified perils requires separate endorsements where available.

Applicant acknowledges that all information provided is material to the acceptance and underwriting of this application; any material misstatement or omission may be grounds for denial of coverage or rescission of the policy. Applicant further acknowledges that coverage is not effective until accepted and issued by the insurer.

I acknowledge the exclusions and statements above and certify that I have disclosed all material information to the best of my knowledge.

Claims / Loss History

In the past five (5) years, has the applicant or any proposed driver or resident had any accidents, claims, losses, or violations? Yes No

Beneficiary / Loss Payee Information

Designated Payee for claim proceeds (mortgagee, lienholder, or beneficiary). If none, leave blank.

Documentation Checklist

The following documents are required to process this application. Attach copies where available and indicate items provided:

Copy of driver license(s)
Vehicle registration(s) / title
Proof of home ownership / deed
Prior declarations page (most recent policy)
Photos of property / 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. I understand that material misrepresentations or omissions may void coverage or render the policy unenforceable. I authorize the insurer to obtain motor vehicle records, credit reports, claims history, and other underwriting information reasonably necessary to evaluate this application. I consent to reasonable inspections of the insured property and to provide additional documentation as requested.

I understand that coverage will not be binding until this application is accepted and a policy is issued by the insurer. I agree that any premium or fees quoted are estimates and final premium will be determined by the insurer's underwriting and applicable policy terms.

Fraud Warning: Any person who knowingly presents false or fraudulent information, or conceals material facts, may be subject to civil and criminal penalties, including denial of benefits.

By signing below, the applicant confirms accuracy of the statements above and authorizes the insurer to use the provided information for underwriting and claims administration.

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