Insurance E-Signature Pages

INSURANCE E-SIGNATURE PAGES

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Entity Type: Individual Corporation Limited Liability Company Other

Policy Details

Policy Type: Property Liability Auto Life Umbrella

Coverage Amount: $    Deductible: $    Annual Premium: $

Policy Period Start:    Policy Period End:

Coverage Selection

Select applicable coverages and indicate limits where required.

General Liability   Limit: $

Property Damage   Limit: $

Business Auto   Limit: $

Exclusions & Endorsements

The following standard exclusions apply to the policy unless an endorsement is attached. Applicant confirms receipt and review of these exclusions:

War or hostilities exclusion acknowledged
Intentional acts and fraud exclusion acknowledged
Pollution and contamination exclusion acknowledged

Beneficiary Designation

Relationship:    Percentage:

Declarations, Consents and Authorizations

By signing below, Applicant certifies that all statements and answers in connection with this application and any attachments are true and complete to the best of Applicant's knowledge. Applicant acknowledges that any material misstatement or omission may permit the insurer to void coverage as permitted by law.

Applicant hereby authorizes the insurer, its agents and service providers to obtain and share such information as necessary to underwrite, quote, bind and service the policy, including but not limited to claim history, motor vehicle records, credit-based insurance scores, loss runs, inspection reports and other consumer reports. Applicant authorizes third parties to release such information to the insurer.

Fraud Notice: Where applicable, any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud and subject to civil and criminal penalties under applicable law.

Electronic Delivery and Signature Consent: Applicant agrees that policy documents, notices and communications may be delivered electronically. Applicant consents to the use of electronic signatures, initials, and checkboxes as legally binding and equivalent to handwritten signatures for all purposes relating to this policy.

ACKNOWLEDGMENT: Applicant acknowledges receipt of and opportunity to review any applicable policy terms, endorsements and disclosures delivered electronically or in paper form, and accepts the coverage, exclusions and limits set forth in the issued policy.

I attest that the information provided in this form is true, accurate and complete.

I consent to electronic delivery of policy documents, billing, notices and communications.

I authorize the insurer and its representatives to obtain information and records necessary to underwrite and service this policy.

Acknowledgment of Electronic Signature

Applicant acknowledges that by signing below electronically, Applicant intends to sign this document and any accompanying policy documents, endorsements and disclosures, and that such electronic signature shall have the same force and effect as a handwritten signature.

Applicant further acknowledges the right to withdraw consent to electronic delivery at any time by providing notice to the insurer in the manner specified within the policy; withdrawal of consent will not affect the legal validity of prior electronic signatures or deliveries.

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