Insurance EIV Form

INSURANCE EIV FORM

Applicant / Insured Information

Client Name:

Date of Birth:    Phone:

Policy Details

Policy Number:    Agent/Broker:

Auto    Homeowners    Life    Disability
Health    Commercial    Other:

Coverage Amount:    Deductible:    Premium (annual):

Policy Period From: to

Coverage Selections

Select coverages and indicate limit where applicable. Limits should reflect policy declarations or requested coverage limits.

Liability Limit: $

Collision    Comprehensive

Personal Property Coverage (Limit): $

Medical Payments    Uninsured/Underinsured Motorist

Replacement Cost    Named Perils    All Risk

Exclusions and Limitations

The following are exclusions or material limitations applicable to the policy unless otherwise endorsed. The insured must disclose any conditions, properties, or activities that may affect underwriting or coverage.

Beneficiary Designation

Designate beneficiaries for proceeds where applicable. Percentage allocations must total 100% for benefits requiring percentages.

Relationship:    Percentage: %

Relationship:    Percentage: %

Electronic Income Verification (EIV) Authorization

By signing this form, the Applicant authorizes the insurer and its authorized agents to obtain and verify income, employment and related eligibility information using electronic income verification systems, third-party wage repositories, and employer contacts as required to determine eligibility, underwriting classification, premiums, and claims handling. The Applicant acknowledges that this verification may include access to wage records, employment status, and income history.

I authorize the insurer to obtain EIV data and related employment/income records for underwriting, rating, and claim adjudication purposes.

Wage repositories and payroll processors    Employer contact and verification    Tax records where authorized

Employer Phone:    Date Hired:

Gross Income Amount: Frequency:

Documentation Checklist

Indicate documents provided or expected to be obtained electronically for income verification.

Recent paystubs (most recent pay periods)    Tax returns / W-2

Bank statements    Employer verification letter

Declaration and Certification

I certify under penalty of perjury that the information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that the insurer will rely on this information and any false statements or material omissions may result in denial of coverage, rescission of the policy, or other remedies permitted by law. I further acknowledge that the insurer may share information with reinsurers, service providers, and regulatory authorities as permitted or required by law.

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