Insurance Auto Home Document

INSURANCE AUTO HOME POLICY APPLICATION AND DECLARATION

Applicant / Insured Information

Client Name:

Date of Birth: Phone:

Policy Details

Policy Number (if applicable):

Auto Homeowners Combined Auto-Home Package

Policy Period: From to

Payment Frequency: Monthly Quarterly Annually

Auto Coverage Selections

Complete for each insured vehicle. If multiple vehicles, attach additional schedule.

Liability Coverage — Limit:

Collision — Deductible: Limit:

Comprehensive — Deductible:

Uninsured/Underinsured Motorist — Limit:

Home Coverage Selections

Complete property information and select coverages to be bound. For condominium or renters, indicate unit/contents only.

Dwelling Coverage — Limit:

Other Structures — Limit:

Personal Property — Limit:

Loss of Use (Additional Living Expense) — Limit:

Personal Liability — Limit:

Optional Endorsements / Additional Coverages

Earthquake Endorsement Flood Endorsement

Identity Theft Coverage Rented Equipment Coverage

Exclusions and Conditions

The following are material exclusions to the coverages sought. Unless an endorsement is expressly added and a premium charged, coverage does not apply to loss or liability caused by: (a) flood or surface water, (b) earthquake or earth movement, (c) wear and tear, gradual deterioration, mold, rust or corrosion, (d) intentional or criminal acts by the insured, (e) nuclear hazard, war, or governmental action. Additional exclusions and conditions are set forth in the policy form that will be issued if coverage is bound.

I acknowledge I have read the exclusions and conditions listed above and agree that material misrepresentation or concealment of facts may render the policy voidable and relieve the insurer of liability.

Acknowledgement: I acknowledge and accept the exclusions and conditions.

Beneficiary / Loss Payee Information

Beneficiary Name:

Relationship to Insured: Percentage: %

Material Facts, Prior Coverage and Loss History

Have you had any claims or losses in the last five years? Yes No

Declarations and Certification

By signing below, the undersigned certifies under penalty of civil and criminal liability that the information contained in this application is complete, true and correct to the best of the undersigned's knowledge. The undersigned further acknowledges that coverage is subject to the terms, conditions, limits and exclusions stated in the policy form and any endorsements issued. The undersigned authorizes the insurer to obtain, verify and share information necessary for underwriting and claims handling, including inspections of the insured property and motor vehicles.

The undersigned understands that any material misrepresentation, fraud or omission in this application may result in denial of coverage, rescission of the policy, or denial of claims. Premiums are due as specified and failure to remit premium when due may result in cancellation in accordance with policy terms.

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