Insurance Auto Signature Docs

INSURANCE AUTO SIGNATURE DOCS

Purpose: This document collects the insured's identification, motor vehicle and policy information, coverage elections, acknowledgments of material terms and exclusions, beneficiary designation for any payable death benefit, and the insured's signature certifying accuracy and consent. By signing below the Applicant/Insured certifies the statements contained herein are true and authorizes the insurer and its agents to obtain, use and share information as set forth in the Certification and Consent section.

Applicant / Insured Information

Date of Birth:

Vehicle Information

VIN:    License Plate:

Policy Details

Policy Period From:    To:

Coverage Selections (select applicable coverages)

Liability Limits: $

Collision — Deductible: $

Comprehensive — Deductible: $

Uninsured/Underinsured Motorist — Limit: $

Medical Payments — Limit: $

Roadside Assistance — Limit: $

Exclusions, Limitations and Acknowledgment

The insured acknowledges that the policy excludes coverage for: intentional acts; use of the vehicle for hire or in a racing event; operation by a driver not listed on the policy who is excluded by endorsement; wear, deterioration, mechanical breakdown, or faulty workmanship; war, insurrection or nuclear hazard; and loss arising while the vehicle is used in violation of law or policy terms. This list is illustrative and not exhaustive.

I acknowledge I have read and understand the principal exclusions and limitations set forth in this document and the actual policy. I understand that failure to disclose material information or making a material misrepresentation may result in denial of coverage, rescission, or other remedies permitted by law.

I acknowledge the exclusions and limitations described above.

Beneficiary Designation (If Applicable)

The insured may designate a beneficiary for any policy benefit payable upon death where such benefit is available under the policy. The insured warrants that beneficiary designations are accurate and that the insurer may rely on this designation until a written change is received and processed.

Authorizations and Assignments

By signing below the insured authorizes the insurer and its authorized representatives to obtain, release and exchange information necessary to underwrite or adjust claims, including medical, employment, vehicle, driving record, and prior insurance information. The insured further authorizes payment of benefits, when applicable, to a repair facility or medical provider for covered losses if a written assignment is executed.

I authorize the release and exchange of information as described above.

Certification and Consent

I certify under penalty of perjury that the information provided on this form is true, complete, and accurate to the best of my knowledge. I acknowledge that any materially false statement or omission may lead to denial of coverage, rescission of the policy, or other legal remedies. I consent to electronic signatures and agree that an electronic or facsimile signature shall have the same force and effect as an original signature.

I understand my rights concerning privacy and data sharing and consent to the insurer's use of my personal information for underwriting, claims handling, and fraud prevention consistent with applicable law.

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