Insurance Auto Liability Quote

INSURANCE AUTO LIABILITY QUOTE

Quote Number:    Prepared Date:

Applicant / Insured Information

Date of Birth:    Driver's License No.:    State:

Vehicle Information (Primary Vehicle)

Year:    Make:    Model:

Primary Use: Personal Commuting Business (non-commercial) Ridesharing / For Hire

Annual Mileage:    Anti-Theft Device Installed:

Driver History

Date of Birth:    Years Licensed:

Any accidents or violations in last 5 years? No Yes — provide details below

Policy Details & Coverage Limits

Policy Type: Liability Only Liability + Uninsured Motorist Full Coverage

Policy Period Start:    End:

Bodily Injury Limit (per person): $    Bodily Injury Limit (per accident): $

Property Damage Limit: $    Uninsured Motorist Limit: $

Collision Deductible: $    Comprehensive Deductible: $

Optional Coverages

Uninsured/Underinsured Motorist    Limit: $

Medical Payments    Limit: $

Rental Reimbursement    Limit per day: $

Roadside Assistance

Estimated Premium & Fees

Base Premium: $    Policy Fee: $

Taxes & Surcharges: $    Total Estimated Premium: $

Exclusions and Important Notices

This quote is an estimate of coverage limits and premium based on the information provided. Coverage will be subject to the terms, conditions, definitions and exclusions contained in the policy contract. The following are examples of common exclusions that may apply: intentional acts, use of vehicle in a racing or speed contest, operation by an unlisted driver, use of the vehicle for hire or public livery without disclosure, operation while under the influence of drugs or alcohol, and loss arising from acts of war or nuclear hazard. Other exclusions and limitations may apply and will be detailed in the issued policy.

Beneficiary / Payee for Claim Proceeds

Primary Payee Name:

Relationship to Insured:    Percentage of Proceeds:

Prior Coverage & Documentation Checklist

Prior insurer in last 12 months:    Policy number:

Documentation provided (select all that accompany this application): Driver's license Vehicle registration Prior declarations page

Certification, Authorization and Conditions

By signing below, the applicant certifies that the information provided in this quote request is true, accurate and complete to the best of the applicant's knowledge. The applicant acknowledges that material misrepresentation or omission of facts may result in denial of coverage, rescission of the policy, or adjustment of premium and coverage. This quote is not an insurance policy and does not bind coverage. Coverage becomes effective only when a policy is issued by an authorized underwriter and the required premium is paid.

The applicant authorizes the insurer and its agents to obtain and use motor vehicle and driving records, claims history, credit information where permitted by law, and other underwriting information necessary to evaluate the application. The applicant further authorizes disclosure of policy and claims information to reinsurers, agents, and authorized persons as permitted by law.

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