Insurance Auto Policy Form

INSURANCE AUTO POLICY FORM

Policy Identification

Policy Number:    Issuing Company:

Agent/Broker:    Agent Code:

Named Insured

Date of Birth:    Phone:    Email:

Policy Period

Effective Date:    Expiration Date:

Vehicle Information (List each vehicle to be covered)

Coverage Selection

Select coverages and specify limits/deductibles. Selection of a coverage constitutes an offer to bind that coverage subject to underwriting approval and receipt of premium.

Premium and Payment

Payment Frequency: Annual    Semi-Annual    Monthly

Exclusions and Limitations

The following are standard exclusions to this policy unless expressly added by endorsement: intentional acts, racing, use by an excluded driver, ordinary wear and tear, mechanical or electrical breakdown not caused by covered peril, loss while used for commercial livery or ride-sharing unless endorsed, and loss arising from nuclear hazard or war. Any coverage provided is subject to the terms, conditions and limits set forth in the policy contract and applicable endorsements.

Conditions and Important Provisions

1. Binding and Effective Date: Coverage becomes effective only upon issuance of the policy by the company and when required premium is paid or payment arrangements accepted. Premium quoted is subject to audit and adjustment to reflect actual exposures.

2. Representations and Warranty: The insured warrants that all statements and representations in this form are true to the best of the insured’s knowledge. Material misrepresentation or fraud entitles the insurer to void coverage or deny claims as permitted by law.

3. Cancellation and Nonrenewal: The insurer may cancel or nonrenew this policy in accordance with applicable law and policy provisions. The insured may cancel by providing written notice to the insurer or agent. Any return premium will be subject to applicable fees and adjustments.

4. Subrogation and Recovery: Upon payment of a loss, the insurer shall be subrogated to the insured’s rights to recover from third parties, and the insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights.

5. Duty to Cooperate: The insured must cooperate with the insurer in the investigation, defense, and settlement of claims, including attending examinations under oath and producing records upon request.

6. Arbitration: Any dispute arising under or in connection with this policy may be submitted to arbitration where permitted by law and pursuant to the arbitration provisions set forth in the policy or applicable endorsement.

Beneficiary / Loss Payee for Total Loss or Settlement

Name:    Relationship:

Optional Endorsements / Riders

Check endorsements to be attached to the policy if approved by the insurer and subject to any additional premium:

  Broad Rental Reimbursement Endorsement      New Vehicle Replacement      Custom Parts & Equipment Coverage

Acknowledgment and Certification

By signing below, the named insured certifies that all information provided in this application is true, complete, and correct to the best of the insured’s knowledge. The insured understands that material misrepresentation or omission may result in denial of coverage or rescission of the policy. The insured authorizes the insurer to obtain motor vehicle reports, driving records, and to inspect vehicles for underwriting and claim purposes. Acceptance of coverage is subject to underwriting approval and payment of any required premium.

Notice Regarding Fraud

Any person who knowingly presents a false or fraudulent claim or application for insurance may be subject to criminal and civil penalties, including fines and imprisonment, as provided by law.

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