Insurance Home and Auto Application

INSURANCE HOME AND AUTO APPLICATION

Applicant / Insured Information

Date of Birth:

Property (Home) Information

Type of Residence:

Year Built:   Construction:

Smoke detectors    Burglar alarm (monitored)    Deadbolt locks    Fire sprinkler system

Home Coverage Requested

Preferred Deductible: $500    $1,000    $2,500    Other:

Automobile Information & Coverage

Vehicle 1 — Year / Make / Model / VIN

Primary Garaging Address (if different):

Pleasure    Commute    Business

Bodily Injury / Property Damage Limit:

Collision Deductible:    Comprehensive Deductible:

Uninsured/Underinsured Motorist    Medical Payments

If additional vehicles, list below (Vehicle 2)

Prior Insurance & Claims History

Have you had any claims, losses or incidents in the past 5 years?  Yes    No

Prior Insurance Carrier (most recent):

Mortgagee / Lienholder / Additional Interested Parties

Beneficiary / Payee for Personal Property

Policy Details & Premium

Policy Type Requested: Homeowners    Automobile

Requested Policy Period — From:   To:

Estimated Annual Premium: $

Electronic Funds Transfer    Credit/Debit Card    Invoice / Other

Required Documentation Checklist

Proof of ownership for home (deed, closing statement)
Prior insurance declarations page (most recent)
Vehicle registration(s)
Photos of residence / scheduled personal property

Exclusions and Important Notices

The policy applied for will include standard exclusions, including but not limited to: loss due to nuclear hazard, war or acts of war, intentional loss by insured, wear and tear, and loss due to lack of maintenance. Additional exclusions, conditions, and limits will be set forth in the policy form and endorsements. Coverage for flood, earthquake, and certain high-value personal property requires specific endorsements or separate policies.

Declarations, Authorizations, and Certification

By signing below, I certify that all statements and answers in this application are complete and true to the best of my knowledge. I understand that any material misrepresentation, omission, or concealment of facts may result in denial of coverage, cancellation of the policy, or rescission in accordance with the terms of the policy and applicable law.

I authorize the insurer and its representatives to obtain and exchange information necessary to underwrite and service the policy, including prior insurance claim history, motor vehicle records, credit information where permitted, and other consumer reports. I authorize release of such information to reinsurers and to those with a legitimate business need.

I acknowledge that coverage will not be effective until the application is approved and the initial premium is received, subject to any interim binding agreement provided in writing by an authorized representative. I understand that premium, coverage, limits, and deductibles will be those shown on the declarations page if a policy is issued.

Acknowledgment of Fraud Notice

I acknowledge that knowingly providing false, incomplete, or misleading information on this application may constitute insurance fraud. Such conduct may be subject to civil and criminal penalties as provided by law.

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