Insurance Caregiver Auto Policy

INSURANCE CAREGIVER AUTO POLICY

Policy Information

Policy Number:    Issuer (Insurer):

Effective Date:    Expiration Date:    Agent/Broker:

Named Insured / Applicant

Date of Birth:    Phone:    Email:

License Issuing State:    License Expiration Date:

Household Drivers

List household drivers who may operate insured vehicles. Use 'Excluded Driver' checkbox to expressly exclude coverage for a listed individual.

Date of Birth:    License #:    Relationship:    Excluded Driver:

Date of Birth:    License #:    Relationship:    Excluded Driver:

Vehicles Insured

Provide information for each vehicle used in caregiving activities.

VIN:    Primary Use: Caregiving / Volunteer transport    Garaging Address:

VIN:    Primary Use: Caregiving / Volunteer transport    Garaging Address:

Coverages Selected

Select coverages applicable to caregiving activities. Limits shown should reflect the monetary amounts purchased.

Liability Coverage    Bodily Injury per person: $    Bodily Injury per accident: $    Property Damage: $

Medical Payments Limit: $    Personal Injury Protection (PIP) Limit: $

Uninsured Motorist Limit: $    Underinsured Motorist Limit: $

Collision Deductible: $    Comprehensive Deductible: $

Caregiver Endorsements & Options

Non-Owned Auto Coverage (covers insured when driving a vehicle not owned by them while performing caregiving duties)    Limit: $

Client Medical Expense Reimbursement (covers medical expenses of transported clients arising from an automobile accident)    Limit: $

Personal Effects Coverage for clients' personal property    Limit: $

Exclusions

This policy does not provide coverage for loss or liability arising from use of any insured vehicle while used for: commercial passenger transport for hire or compensation; delivery services for which a fee is charged; intentional acts; operation by a driver excluded on the policy; operation while under the influence of alcohol or controlled substances; or any vehicle while used in the commission of a felony. Additional exclusions may apply as set forth in the policy form.

Conditions & Duties After Loss

The insured must: (a) give prompt notice to the insurer of any claim or loss; (b) forward immediately any legal papers received in connection with a claim; (c) cooperate with the insurer in defense, settlement, and subrogation; (d) submit to examination under oath upon request; and (e) take reasonable steps to protect property from further damage. Failure to comply may result in denial of coverage where prejudice to the insurer occurs.

Premium, Payment & Cancellation

Total Premium: $    Payment Plan:

Insurer may cancel for nonpayment of premium or for material misrepresentation. In the event of cancellation by insurer, written notice will be provided to the first named insured in accordance with policy provisions. The effective date of cancellation will be specified in the notice.

Beneficiary — Accidental Death Benefit (if applicable)

Provide beneficiary information for any accidental death benefit included under this policy.

Relationship:    Percentage: %

Claims — Initial Report

In the event of an incident that may give rise to a claim under this policy, complete the following and submit supporting documentation as required by the insurer's claim procedures.

Documentation Checklist (attach copies as required):

Police Report

Photos of Scene / Damage

Medical Records / Bills

Receipts for Repairs / Expenses

Declarations & Certification

By signing below the applicant warrants that the information provided in this application and any attached statements is true, complete, and made for the purpose of obtaining the insurance described in this policy. The applicant acknowledges that any material misrepresentation, omission or concealment of fact may result in rescission of the policy or denial of coverage. The insurer is authorized to make inquiries and verify any information provided.

The insured understands that coverage under this policy is limited to personal and volunteer caregiving activities as expressly described in the endorsements. Use of insured vehicles for commercial, hired, or compensated passenger transport is not covered unless specifically endorsed. The insured agrees to cooperate with the insurer in claims handling and subrogation efforts.

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