Insurance Auto Supplement Application

INSURANCE AUTO SUPPLEMENT APPLICATION

Applicant / Insured Information

Vehicle Information (Supplement)

Year: Make: Model:

Additional Drivers to Be Insured

Driver 1 - Full Name: DOB:

Driver 2 - Full Name: DOB:

Policy Details & Coverage Requested

Loss History & Exclusions

Prior Claims / Loss Details (if applicable)

Lienholder / Loss Payee

Beneficiary Information (for medical / policy proceeds where applicable)

Documentation Checklist

Please indicate which supporting documents are attached with this supplement:

Declarations, Authorizations and Notices

I, the undersigned Applicant, declare that the information provided in this Insurance Auto Supplement Application is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may be grounds for denial of coverage, rescission of the policy, or cancellation in accordance with the terms of the policy and applicable law.

I authorize the insurer, its agents and representatives to obtain and verify information regarding my driving record and loss history, and to obtain any motor vehicle reports, claims reports or other underwriting information reasonably necessary for underwriting, rating, claims handling and fraud prevention. I authorize any person or entity that has such information to disclose it to the insurer.

I acknowledge that coverage for the vehicle described on this supplement is subject to the terms, conditions, exclusions and limits set forth in the policy. This supplement does not bind coverage unless accepted by the insurer and endorsed to the policy in writing. Any requested changes will become effective only upon issuance of a policy endorsement or written confirmation.

Fraud Warning: Where permitted by law, any person who knowingly and with intent to defraud any insurance company files an application containing false information or conceals for the purpose of misleading, material facts may be guilty of insurance fraud and subject to civil and criminal penalties.

Subrogation and Recovery: I agree to assist and cooperate with the insurer in preserving the insurer's rights against any third party responsible for a loss, including signing any documents necessary to effectuate subrogation or recovery efforts.

Applicant Certification

By signing below I certify under penalty of perjury that the statements made in this supplement are true and complete. I understand that the insurer may rely on these statements in determining coverage and premium. I further certify that I have the authority to provide the information and authorizations contained herein.

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