Insurance Auto Packet

INSURANCE AUTO PACKET

Applicant / Insured Information

Date of Birth:

Vehicle Information — Vehicle 1

Additional Vehicle (Optional)

Drivers — Primary and Additional

Coverage Selection

Select coverages requested and indicate limits or deductibles where applicable. Coverage provided is subject to policy terms, conditions, endorsements, and eligibility.

Policy Period, Premium & Payment

Requested Effective Date: Termination Date:

Exclusions & Endorsements

The policy will contain exclusions including, but not limited to: intentional acts, use of the vehicle for commercial livery or delivery unless specifically endorsed, non-permitted drivers, racing or speed contest participation, and loss from wear and tear or mechanical failure. Insurer may decline coverage for misrepresentations on this packet.

Beneficiary — Death Benefits (if applicable)

Designate a beneficiary for covered death benefits under personal injury or medical payment coverages where allowed by the policy.

Loss & Claims History

Provide prior losses for all vehicles and drivers for the prior five (5) years. Failure to disclose material loss history may be grounds for denial or rescission.

Documentation Checklist (for new policies or claims)

Provide copies of the following as applicable. Failure to submit necessary documentation may delay underwriting.

Declarations, Authorizations & Fraud Warning

I certify that the information provided in this Insurance Auto Packet is true, complete and accurate to the best of my knowledge. I understand that material misrepresentations, omissions, or false statements may result in denial of coverage, rescission of the policy from inception, forfeiture of premiums, or civil and criminal penalties as permitted by law.

I authorize the insurer and its representatives to obtain motor vehicle records, claim history, credit information where permitted by law, and other underwriting information necessary to evaluate this application and any future policy changes. Such information may be used to verify statements made herein, to determine insurability, and to respond to claims.

I understand the policy will be issued subject to terms, conditions, exclusions, and endorsements. Acceptance of any policy is expressly conditioned on underwriting approval and receipt of any required premium. I agree to promptly notify the insurer of any material change in risk, including changes in garaging address, primary uses of the vehicle, or additional drivers.

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