Insurance Group Auto Application

INSURANCE GROUP AUTO APPLICATION

Applicant / Group Information

Group Name:

Policy Details Requested

Requested Effective Date:    Requested Term (months):

Liability (Bodily Injury & Property Damage)    Comprehensive    Collision    Medical Payments    Uninsured/Underinsured Motorist    Hired / Non-Owned Auto

Coverage Limits & Deductibles

Desired Liability Limit per occurrence: $

Collision Deductible: $    Comprehensive Deductible: $

Vehicles to Be Insured (Provide complete vehicle information)

Vehicle 1 — Year: Make: Model:

VIN:

Vehicle 2 — Year: Make: Model:

VIN:

Drivers (List all drivers to be covered)

Driver 1 — Full Name:

Date of Birth: Driver's License #: State:

Years Licensed: Accidents in last 5 years: Violations in last 3 years:

Loss History & Prior Insurance

Has the group or any listed driver had any automobile accident, loss or claim in the past five (5) years?   Yes    No

Prior Carrier Name:    Policy Number:

Yes    No

Coverage Selections (Specify limits where applicable)

Bodily Injury Liability — Per Person: $ Per Accident: $

Property Damage Liability — Limit: $

Uninsured/Underinsured Motorist — Per Person: $

Comprehensive — Deductible: $ Collision — Deductible: $

Medical Payments Limit: $

Exclusions and Important Notices

The following standard exclusions apply unless expressly amended in a written endorsement issued by the insurer: intentional loss or acts by an insured, use of a vehicle for unauthorized livery or for hire when not endorsed, operation by an excluded driver, wear and tear or mechanical breakdown, nuclear hazard, war, and punitive damages where prohibited by law. Any other exclusions or limitations will be stated on the policy declarations.

By submitting this application the applicant acknowledges that the insurer will rely upon the truthfulness and completeness of the information provided. Material misrepresentation or concealment of information may result in denial of coverage, rescission, or adjustment of premiums and coverage effective date.

Beneficiary Designation

Beneficiary 1 — Name:

Relationship:    Percentage: %

Documentation Checklist

Current vehicle inventory listing    Driver roster with license details    Loss runs for prior five years    Prior policy declarations

Authorization and Certification

The undersigned applicant certifies that to the best of their knowledge the statements contained in this application are true and complete. The undersigned authorizes the insurer, its agents and representatives to obtain and verify any information deemed necessary for underwriting and servicing the policy, including motor vehicle records, claims history, and credit information where permitted by law. The applicant agrees that any material misstatement or omission of fact may constitute grounds for denial of coverage or rescission of the policy retroactive to its inception.

The applicant further acknowledges that premium, terms, conditions, and any applicable endorsements will be shown on the policy declarations and that coverage will not be in effect until the insurer accepts this application and issues a policy or binder. Acceptance of this application by the insurer does not waive any inspection, audit, or verification rights.

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