Insurance Auto Switch Form

INSURANCE AUTO SWITCH FORM

This Insurance Auto Switch Form is submitted by the Applicant to request a change in automobile insurance coverage, to authorize release of prior policy and claims information, and to declare factual statements for underwriting and policy issuance. Applicant certifies that all statements below are true, complete and made for the purpose of obtaining revised insurance coverage. Misrepresentation or omission may result in denial of coverage, rescission, or retroactive premium adjustments.

APPLICANT / INSURED INFORMATION

CURRENT POLICY / NEW POLICY INFORMATION

Current Insurer:    Policy Number:

New Insurer Requested:    Requested Effective Date:

VEHICLE INFORMATION

Year:   Make:   Model:

Primary Use:   Odometer Reading:

COVERAGE SELECTION (Select all that apply)

Liability   Limit:

Collision   Deductible:

Comprehensive   Deductible:

Uninsured/Underinsured Motorist   Limit:

Medical Payments   Limit:

PRIOR CLAIMS / DRIVER RECORD

Any accidents or claims in the last 5 years?    Yes    No

Any license suspensions, revocations or major violations in last 5 years?    Yes    No

LIENHOLDER / ADDITIONAL INTEREST (IF APPLICABLE)

BENEFICIARY / LOSS PAYEE (IF APPLICABLE)

EXCLUSIONS, ENDORSEMENTS & SPECIAL INSTRUCTIONS

AUTHORIZATION, CONSENTS AND CERTIFICATION

By signing below, the Applicant certifies that the foregoing statements are true and complete to the best of Applicant's knowledge. Applicant authorizes the release of motor vehicle records, policy and claims history to the requested insurer and its representatives for underwriting, rating and claims handling. Applicant understands that any material misrepresentation may be grounds for rescission or denial of coverage and may affect claim payment. Applicant further authorizes the prior insurer named above to furnish policy, premium and claim information to the requested insurer.

Applicant consents to verification of credit and other consumer report information where permitted by law for the purpose of determining insurance premium, eligibility and terms. Applicant understands that coverage will not be effective until the new insurer issues confirmation of coverage and any required premium is paid in accordance with insurer requirements.

Applicant authorizes electronic signatures and delivery of policy documents where permitted. Applicant acknowledges receipt of any required notices delivered contemporaneously with this request.

Consent to Release Claims and Driving Records:    I authorize release    I do not authorize release

DECLARATION

I declare under penalty of perjury that the information provided in this form is complete and true. I understand that the requested change may result in cancellation of existing coverage and that I remain responsible for any lapse in coverage until replacement coverage is effective. I agree to notify the insurer promptly of any material changes to the information supplied.

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