Insurance DF Application

INSURANCE DF APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth:   Social Security Number:

Policy Details Requested

Policy Type: Liability Property Comprehensive

Proposed Policy Period Start:   End:

Coverage Options & Limits

Select coverages to be considered (check all that apply):

Collision Coverage
Comprehensive Coverage
Medical Payments
Personal Injury Protection (PIP)
Uninsured / Underinsured Motorist
Other

Exclusions and Special Terms

The policy, if issued, will include exclusions customary to the selected policy type including but not limited to intentional acts, willful misconduct, nuclear hazard, war, and losses arising from illegal activity. Applicant must disclose known exposures or requested endorsements, and the insurer reserves the right to deny coverage for undisclosed material facts.

Beneficiary Designation

Primary Beneficiary Name:

Relationship:   Percentage:

Health, Risk & Prior Insurance

Have you smoked or used tobacco in the last 12 months? Yes No

Do you have any pre-existing medical conditions or pending claims? Yes No

Have you had prior insurance declined, cancelled, or rated higher than standard? Yes No

Declaration, Authorization & Certification

By signing this application, the Applicant certifies that all statements and answers contained herein are true and complete to the best of the Applicant's knowledge and belief. The Applicant understands that any material misrepresentation, omission, or fraudulent statement may be grounds for rescission of coverage or denial of a claim and may subject the Applicant to civil or criminal penalties under applicable law.

The Applicant authorizes any medical provider, employer, insurer, consumer reporting agency, or attorney to release medical, employment, claims, or other relevant records to the insurer and its representatives for the purpose of underwriting, claims handling, and fraud prevention. A photographic or electronic copy of this authorization shall be as valid as the original.

Premiums are due as agreed upon in the policy contract. Coverage is not effective until the insurer issues a policy or binder and the required premium or deposit is received, unless a temporary binder is issued in writing by the insurer.

I consent to receive policy documents, notices, and communications electronically where permitted by law.

Attestation

I hereby declare that I have read and understand the statements contained in this application. I attest that the information provided is true and complete and agree that this application shall form the basis of any policy issued. I understand that the insurer may require additional information or documentation to evaluate this application.

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