Insurance Consumer Consent Form

INSURANCE CONSUMER CONSENT FORM

Insurer Name:   Agent/Broker:

Applicant / Insured Information

Policy Details

Policy Period: From to

Coverage Selections

Indicate elected coverages by checking each box that applies. Checking a box authorizes the insurer to include the selected coverage in underwriting and premium calculation.

Liability Coverage

Collision Coverage

Comprehensive Coverage

Personal Injury Protection

Uninsured / Underinsured Motorist

Authorizations and Consents

By signing below, the applicant expressly authorizes the insurer, its agents, affiliates, reinsurers, representatives and service providers to collect, use, verify and disclose personal information and records as described in this consent for the purposes of underwriting, policy administration, claims handling, fraud detection, rating, and reinsurance. Personal information may include but is not limited to: consumer credit reports, motor vehicle records, medical and prescription records, employment and income verification, claim history, and other relevant insurability information.

I authorize the insurer to obtain and use consumer reports, credit information and other investigative consumer reports for underwriting and renewal decisions.

I authorize the insurer to request and receive medical, hospital and prescription records related to any claim or underwriting review.

I authorize the insurer to obtain motor vehicle records and driving history for any driver listed on the policy.

I authorize sharing of information with affiliates, reinsurance partners and service providers where necessary to administer coverage, claims, and loss control.

I consent to receive communications and disclosures electronically, including policy documents and claim correspondence, unless I revoke this consent in writing.

Exclusions and Limitations

The following are typical exclusions that may apply to the coverages selected. The insurer's policy terms, endorsements and declarations will control the scope of coverage. The applicant acknowledges that the insurer may rely on underwriting information and that coverage may be limited or denied for material misrepresentations or non-disclosure.

Beneficiary Designation

Complete beneficiary information for any benefits payable under the policy. If more than one beneficiary is named, indicate the percentage share for each. If no beneficiary is designated, proceeds will be distributed in accordance with the insurer's default rules.

Acknowledgement and Certification

The applicant acknowledges that all information provided in this form and any attachments is true, correct and complete to the best of the applicant's knowledge. The applicant understands that the insurer will rely on this information in underwriting, issuing and pricing the policy. The applicant further acknowledges that intentionally providing false or misleading information may result in denial of coverage, cancellation of the policy, and other remedies permitted by law.

Revocation: This consent may be revoked by the applicant at any time by written notice to the insurer or agent named on this form. Revocation will not apply to information already shared or actions already taken by the insurer in reliance on this consent prior to receipt of notice of revocation.

Duration: Unless revoked earlier, this consent remains in effect for the period necessary to process underwriting, claims and policy administration, including renewals and loss history reporting, and for a reasonable period thereafter for record retention, audit and reinsurance purposes.

Certification: I certify under penalty of law that the information provided on this form is true, complete and correct to the best of my knowledge and belief.

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