Insurance Home and Life Policy Application

Insurance Home and Life Policy Application

Applicant / Insured Information

Single Married Domestic Partnership Widowed Separated

Property / Dwelling Information

Owner-occupied Rented to others Vacant Seasonal / Secondary

Home Coverage Selections

Coverage A — Dwelling: $    Coverage B — Other Structures: $

Coverage C — Personal Property: $    Coverage D — Loss of Use (limit or %):

Personal Liability Limit: $    Medical Payments Limit: $

Deductible (per occurrence): $

Replacement Cost on Dwelling Scheduled Personal Property Water Backup / Sump Overflow Flood (subject to separate underwriting) Earthquake Home Business Liability Identity Theft Expense Ordinance or Law (increased cost of construction) Inflation Guard

Prior Losses / Claims

Yes No

Life Coverage Selections

Term Life Whole Life Universal Life

Face Amount: $    Term Length (if applicable):

Yes — used within past 5 years No

Beneficiary Designation

Policy Details

Policy Period Start:    End:

Requested Effective Date:    Estimated Annual Premium: $

Monthly Quarterly Semi-Annual Annual

ACH / Bank Draft Check Credit Card

Declarations, Authorizations and Notices

I hereby declare that the statements and answers contained in this application are true, complete and correctly recorded. I understand that material misrepresentation or omission of fact may give the insurer the right to rescind the policy, deny a claim, or adjust coverage and premium consistent with the policy terms. Acceptance of this application by the insurer is subject to underwriting review and approval.

I authorize any physician, medical practitioner, hospital, clinic or other medically related facility, insurer, consumer reporting agency, employer, or other organization or person having records or knowledge of me or my health to disclose such information to the insurer for underwriting, claim handling and fraud prevention. I authorize the release of relevant information to reinsurers, affiliates, and service providers for these purposes. I understand that a photographic or electronic copy of this authorization shall be as valid as the original.

I further authorize the insurer to obtain motor vehicle records, credit reports and claims history as necessary to underwrite this application and verify underwriting information. I understand that coverage, if issued, will be governed by the terms and conditions of the policy form and endorsements issued by the insurer, and that any binder or temporary insurance is effective only when expressly provided in writing by the insurer or its authorized agent.

Fraud Warning: Any person who knowingly submits an application containing false, incomplete or misleading information may be subject to civil and criminal penalties, including denial of coverage and claim payment. This fraud warning is provided to the fullest extent permitted by applicable law.

By checking the box below I acknowledge and affirm that I have read and understand the declarations and authorizations in this application and that the information provided is true and complete to the best of my knowledge.

I acknowledge and agree to the above declarations and authorizations.

Additional Information

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