Insurance Auto Remarket Application

INSURANCE AUTO REMARKET APPLICATION

Applicant / Insured Information

Vehicle Information (Each vehicle to be remarked)

Vehicle Condition:

Title Status: Clean Salvage Rebuilt/Reconstructed Unknown

Intended Remarketing Method: Auction Dealer Sale Consignment Online Sale Other:

Policy Details

Policy Type: Physical Damage Liability Transit/Transport Storage/Garagekeepers Test-Drive Coverage

Policy Period: From to

Coverage Options (Select all that apply)

Collision Comprehensive Uninsured Motorist Underinsured Motorist Medical Payments Roadside Assistance Rental Reimbursement Theft Protection Test-Drive Liability Coverage

Exclusions and Conditions

The following are standard exclusions under this application and any resulting binder or policy unless expressly endorsed: losses arising from intentional damage, wear and tear, mechanical or electrical breakdown not caused by covered peril, racing or speed contests, use for hire or livery unless specifically endorsed, damage caused by unlawful acts of the insured, and loss to property held for sale by a third‑party purchaser prior to transfer of title. Applicant acknowledges that additional exclusions may be set forth in the policy document.

I acknowledge and accept the exclusions set forth above and understand that coverage is subject to the terms, conditions and endorsements of the issued policy.

Loss Payee / Beneficiary / Lienholder

Prior Losses & Risk History

In the past five (5) years, has the applicant had any motor vehicle losses, total loss declarations, or thefts? Yes No

Security and Storage Controls

Security measures in place at storage location: Locked Garage Fenced Lot Video Surveillance Alarm System None

Certification, Representations and Authorization

The Applicant certifies that the information contained in this application is true, complete and correct to the best of Applicant's knowledge and belief. Applicant understands that this application, any attachments and all statements made herein will be relied upon by the insurer in determining whether to issue a binder or policy and on what terms. Applicant agrees to notify the insurer promptly of any material change in the information provided prior to issuance of the policy.

Applicant hereby authorizes inspection of the vehicle(s) and storage location(s) by an authorized representative of the insurer and consents to the insurer obtaining historical claims and title information from third‑party databases as necessary to underwrite the risk. Applicant acknowledges that premium, coverages and conditions are subject to verification and may be adjusted upon inspection or review of additional documentation.

False statements, omissions or misrepresentations may result in denial of coverage, rescission of the policy, or cancellation as permitted by law. Applicant understands that the issuance of a binder, endorsement or policy does not create coverage for risks not applied for or risks excluded by the terms of the policy.

By signing below, I certify under penalty of perjury that the statements made on this application are true and complete. I agree that this application shall be the basis of any policy issued and that no coverage is effective until accepted and confirmed by the insurer in writing or other authorized binder documentation.

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