Insurance Auto Request Form

INSURANCE AUTO REQUEST FORM

Use this form to request new automobile insurance coverage, request an endorsement, or update existing policy information. Complete all applicable fields. The information provided is relied upon to evaluate coverage eligibility and premium. Intentional misrepresentation may result in denial of coverage or rescission.

Applicant / Insured Information

Date of Birth:

Driver's License Number: State:

Vehicle Information (Vehicle 1)

Policy Details Requested

Select requested coverages (check all that apply):

Liability

Collision

Comprehensive

Uninsured / Underinsured Motorist

Personal Injury Protection (PIP)

Rental Reimbursement / Transportation Expense

Requested Policy Period: Effective through

Prior Insurance and Driving History

Prior insurance in the last three years: Yes No

Have you had any accidents or moving violations in the last five years? Yes No

Exclusions and Special Conditions

The requested policy will not cover loss or liability caused by: intentional acts; operation of the vehicle for hire without specific endorsement; use of the vehicle in competitive racing or speed contests; operation by a person who is excluded from coverage or whose license is suspended or revoked; wear and tear, mechanical breakdown, or gradual deterioration; nuclear hazard or war. Additional exclusions may apply per the policy form and endorsements issued.

I acknowledge that I have read and understand the common exclusions set forth above and that further exclusions may appear in the policy and endorsements.

Beneficiary / Loss Payee (if applicable)

Documentation Checklist

Please attach or provide the following upon submission where applicable: copies of driver's license, current declarations page, vehicle registration, current photographs of vehicle(s), loan/lease agreement for financed or leased vehicles, and police reports for recent accidents. Failure to provide required documentation may delay underwriting.

Declaration and Authorization

I hereby declare that the information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that this form is a request for insurance coverage and does not itself bind coverage. I understand and agree that any material misrepresentation or omission in this application may constitute fraud and may be the basis for rescission or denial of coverage as permitted by law and the terms of any issued policy.

I authorize the insurer and its agents to obtain my motor vehicle records, claims history, and other underwriting information necessary to evaluate this request. I further authorize consumer reporting agencies to disclose credit-related information for underwriting and rating purposes where permitted by law. I consent to any inspections of the described vehicle(s) as required by the insurer.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company files an application containing false information or conceals information for the purpose of misleading may be guilty of insurance fraud. I acknowledge receipt of the above statements and certify under penalty of perjury that the foregoing is true and correct.

I certify that the information provided is true and that I am authorized to make this request on behalf of all proposed insureds.

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