Insurance Automobile Application

INSURANCE AUTOMOBILE APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth:    Driver's License No.:

State of License:    Primary Phone:    Email:

Vehicle Information

Year:    Make:    Model:

Vehicle Identification Number (VIN):

Current Odometer: miles    Primary Use:

Policy Requested / Coverage

Requested Policy Period: From to

Select coverage types (check all requested):

Liability    Collision    Comprehensive    Uninsured/Underinsured Motorist

Bodily Injury Limit per Person: $    Bodily Injury Limit per Accident: $    Property Damage Limit: $

Collision Deductible: $    Comprehensive Deductible: $

Drivers to be Insured

Driver 1

Full Name:    DOB:

Driver's License No.:    State:    Years Licensed:

Principal Operator:    Relationship to Applicant:

Driver 2

Full Name:    DOB:

Driver's License No.:    State:    Years Licensed:

Principal Operator:    Relationship to Applicant:

Driving & Claims History

Has any driver proposed for insurance had any accidents, claims, or losses in the past five (5) years? Yes No

Any driver's license suspended, revoked, or had restrictions in the past five (5) years? Yes No

Prior Insurance / Cancellations

Current or most recent insurer:    Policy No.:

Has any policy been cancelled or non-renewed in the last three (3) years? Yes No

Optional Coverages & Exclusions

Request Roadside Assistance:    Rental Reimbursement:

The policy will not cover loss or liability arising from: intentional or criminal acts by the insured; use of the vehicle in organized racing; operation by drivers not listed or otherwise permitted under the policy; or use of the vehicle as a public livery or for hire unless specifically endorsed. Applicant acknowledges these standard exclusions.

Beneficiary for Return of Unearned Premium

Beneficiary Name:

Relationship:    Percentage of Benefit:

Declarations, Certification & Authorization

The undersigned declares that all statements in this application are true and complete to the best of their knowledge. The applicant understands that material misrepresentation, omission, or concealment of facts may constitute fraud and may result in denial of coverage or rescission of the policy.

By signing below, the applicant authorizes the insurer and its representatives to obtain motor vehicle records, to access prior insurance and claims history, and to verify any other information relevant to underwriting and rating. This authorization remains valid for purposes of underwriting, claims handling, and policy servicing.

Applicant acknowledges that coverage will be effective only upon issuance of a policy and receipt of required premium, subject to all policy terms, conditions and exclusions.

I acknowledge that the statements contained in this application become a part of any policy issued and are relied upon by the insurer in issuing coverage.

Applicant Signature Consent:

Sign Now