Insurance Automobile Policy

INSURANCE AUTOMOBILE POLICY

Policy Declarations

Policy Number:   Insurer:

Policy Period: From through (12:01 a.m. standard time at the insured location)

Insured Information

Date of Birth:   Primary Contact Phone:   Email:

Vehicle Schedule

Complete a separate line for each covered vehicle.

VIN:   Garaging Address:

Primary Use:   Agreed Value / Insured Value: $

VIN:   Garaging Address:

Named Drivers

Driver's License #:   State of Issue:   DOB:

Driver's License #:   DOB:

Coverages and Limits

Select the coverages provided by this policy and state limits/deductibles where applicable.

Liability — Bodily Injury per person: $   Per accident: $

Liability — Property Damage per accident: $

Medical Payments: $

Uninsured/Underinsured Motorist — Bodily Injury per person: $   Per accident: $

Collision Coverage — Deductible: $ Limit: $

Comprehensive Coverage — Deductible: $ Limit: $

Exclusions (Representative)

The following exclusions apply unless added by endorsement. This list is illustrative; the policy's Exclusions section governs.

Losses due to intentional acts or illegal use by an insured.

Losses while vehicle is used in competitive racing, speed testing, or stunts.

War, insurrection, nuclear hazard, and governmental seizure.

Premium, Fees and Payment Terms

Annual Premium: $   Policy Fees: $

Total Due at Inception: $   Payment Frequency: Annual Semi-Annual Monthly

Installment Plan Details / Agency Billing Instructions:

Loss Payee / Designated Payee

If insurance proceeds are payable to a third party (e.g., lienholder), identify below.

Relationship to Insured:   Percentage Payable: %

Conditions, Duties and Key Provisions

Insuring Agreement — Subject to the declarations, definitions, conditions, exclusions, limits and endorsements of this policy, the Company will pay on behalf of the Insured those sums that the Insured is legally obligated to pay as damages resulting from a covered automobile loss occurring during the policy period.

Duty to Cooperate — The Insured shall give the Company prompt notice of any incident likely to give rise to a claim, cooperate with the Company in the investigation, provide written proof of loss when requested, and submit to examination under oath with respect to matters relating to the claim. Failure to comply with these duties may result in denial of coverage to the extent the Company is prejudiced.

Subrogation — To the extent of payment, the Company shall be subrogated to any rights of recovery the Insured may have against any person or organization. The Insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights.

Salvage and Appraisal — After total loss payment, title to the salvage, if any, shall pass to the Company unless otherwise agreed. In case of dispute as to the amount of loss, either party may demand appraisal as provided in the policy.

Cancellation / Nonrenewal — This policy may be canceled or nonrenewed in accordance with the cancellation provisions set out in the policy. Premium adjustment on cancellation will be made in accordance with the policy's stated method (pro rata or short rate if applicable).

Claims Reporting and Documentation

Date of Loss:   Location of Loss:

Documentation Checklist (attach originals to claim file):

Police report (if applicable)    Photographs of damage    Repair estimate(s)

Endorsements and Special Provisions

Declaration and Certification

By signing below, the Named Insured certifies that the statements and answers contained in this application and policy declarations are true, complete and are material to the risk assumed by the Company. The Insured understands that material misrepresentation or omission may void coverage from the inception of the policy or from the date of the misrepresentation, as provided by law and the policy terms.

The Insured authorizes the Company to obtain motor vehicle records, claim history and other underwriting information necessary to issue and service the policy. The Insured further agrees to comply with all policy conditions, including prompt payment of premium and notification of additional drivers or changes in use that materially increase the risk.

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