Insurance Auto Re-sign Form

Insurance Auto Re-sign Form

Purpose: This form is used to re-execute and confirm the insured's signature and acknowledgement of the policy and related underwriting information for the motor vehicle policy identified below. Completion and signature by the insured constitutes a representation that the information provided is true and correct, that the insured authorizes verification of the information, and that re-signing does not amend coverage except where indicated in writing below.

Applicant / Insured Information

Policy Details

Policy Number:    Insurer Name:

Policy Period From: to

Vehicle Information

Reason for Re-signature & Authorization

Select the reason(s) for re-signing (check all that apply):

Renewal acknowledgement
Original signature lost or damaged
Electronic signature not captured or rejected
Change of named insured or policyholder data
Other:

Coverage Acknowledgment

By checking the boxes and providing limits/deductibles you confirm your understanding of the current coverages and limits in force on the policy.

Liability Coverage — Bodily Injury/Property Damage Limits:

Collision — Deductible:

Comprehensive — Deductible:

Uninsured/Underinsured Motorist — Limits:

Medical Payments — Limit:

Exclusions & Important Notices

The insured acknowledges the following common exclusions and affirms they have reviewed the policy exclusions section. Check each box to indicate acknowledgement.

Exclusion for wear and tear, mechanical breakdown, and gradual deterioration
Exclusion for intentional acts and illegal operation of vehicle
Exclusion for unlisted drivers where policy requires prior disclosure
Exclusion for competitive or speed racing events

Prior Claims / Loss History

In the past five years, has the insured or any regular driver on the policy been involved in an accident or had a claim (including theft)? Yes No

Beneficiary / Loss Payee Information

If a lienholder, loss payee or beneficiary designation applies, provide details below. This designation applies only to loss payment and does not confer ownership of the policy.

Declarations, Certification & Consent

I, the undersigned insured, declare under penalty of perjury that the information provided on this Insurance Auto Re-sign Form is true, accurate and complete to the best of my knowledge. I understand that the insurer may rely on these statements and that any material misrepresentation or omission may result in denial of coverage or rescission of the policy in accordance with applicable law and policy terms.

I authorize the insurer and its representatives to obtain, use and verify underwriting and claims information, including motor vehicle records, claims histories, and other relevant information for the purpose of policy issuance, renewal, or adjustment where permitted by law. Re-signing this form is intended only to reconfirm my signature and acknowledgement of existing policy terms and does not constitute a stand-alone endorsement or change to coverage unless changes are specifically documented and signed below.

Acknowledgement of Truthful Execution

By signing below I acknowledge that I have read and understood the foregoing declarations and that my signature below is my true and binding signature for the purposes of this policy record.

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