Insurance Cover Application

INSURANCE COVER APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth:    Identification No. (SSN/Tax ID):

Policy Details

Policy Type (select all that apply):

Auto   Homeowners   Life   Health   Commercial   Other

Policy Period From:    To:

Coverage Options

Select coverage options requested:

Property / Buildings Coverage

General Liability

Medical Payments

Personal Injury Protection

Collision

Comprehensive

Uninsured/Underinsured Motorist

Replacement Cost

Business Interruption

Exclusions & Special Notices

The coverage applied for is subject to policy terms, conditions, limitations and exclusions. Material misrepresentation, omission, or failure to disclose facts material to the risk may render the policy voidable, permit premium adjustment, or allow rescission as permitted by law. The insurer's obligation to provide coverage is subject to acceptance of this application, underwriting review, and issuance of a policy document.

Prior Insurance & Claims History

Any claims in the past five (5) years? Yes No

Has any insurer declined, cancelled or non-renewed coverage for you in the past five (5) years? Yes No

Beneficiary Designation

Beneficiary Name:

Supporting Documentation Checklist

Proof of Identity (government ID)

Prior Policy Declarations

Photographs or Damage Evidence

Property/Vehicle Inspection Report

Medical Records Authorization (if applicable)

Declarations, Authorizations & Fraud Warning

I hereby declare that the foregoing statements and answers are true and complete to the best of my knowledge and belief. I understand that this application, together with any attachments and any statements made in connection with it, shall form the basis of the insurance contract. I further understand that any material misrepresentation, concealment or omission of fact may entitle the insurer to rescind the policy or deny claims in whole or in part in accordance with applicable law.

I authorize the insurer, its representatives, and any designated agents to make inquiries and obtain information from third parties, including prior insurers and claims databases, medical facilities, employers, and public records, as necessary to evaluate this application and any claim. I authorize release of such information to the insurer. A photographic or electronic copy of this authorization shall be as valid as the original.

NOTICE: Fraudulent statements, omissions, or attempts to obtain insurance benefits by fraud are grounds for criminal and civil penalties under applicable law. If applicable, the undersigned affirms that the loss described in any future claim occurred as stated and was not caused intentionally or by willful misconduct.

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