Insurance Member Application

INSURANCE MEMBER APPLICATION

Application Date:

Applicant Information

Month:   Day:   Year:

Preferred Contact Method:    Email    Phone    Mail

Policy Details

Policy Type:    Individual    Family    Group    Commercial

Policy Period: From to

Coverage Selections

Select coverage options to be included in this policy (check all that apply):

Bodily Injury Liability    Property Damage Liability    Collision    Comprehensive

Medical Payments    Uninsured/Underinsured Motorist    Personal Liability    Additional Coverages (see description below)

Prior Insurance & Claims History

Any claims or losses in the past five (5) years?    Yes    No

Beneficiary Designation

Designate one or more beneficiaries for policy proceeds. Percentages must total 100%.

Exclusions

The following are material exclusions commonly applied to policies issued pursuant to this application. The insurer may deny coverage for losses arising from:

• Intentional acts or fraudulent conduct by the insured;
• Losses arising from war, nuclear hazard, or governmental seizure unless specifically endorsed;
• Losses resulting from criminal activity or use of the insured property/vehicle for unlawful purposes;
• Contractual liability except to the extent the insured would have had liability absent the contract.

I acknowledge that exclusions, limitations and endorsements will be stated in the policy and that coverage effective only as stated in the policy documents issued by the insurer.

Acknowledgement of Exclusions: I have read and understand the exclusions set forth above.

Authorizations, Declarations & Certifications

By signing this application the applicant certifies that all statements made in this application are true and complete to the best of the applicant's knowledge and belief. The applicant acknowledges that any material misrepresentation or omission made in this application may be the basis for denial of coverage, rescission of the policy or other remedies permitted by law.

Authorization to Obtain Information: The applicant authorizes the insurer and its agents to obtain motor vehicle, claims, medical (when applicable), employment, credit and other relevant records necessary to evaluate this application, to underwrite, to administer the policy, and for claims handling. This authorization includes the right to exchange relevant information with other insurers and their agents.

Data Use and Privacy: Information provided will be used for underwriting, rating, policy issuance, claims handling and fraud prevention. Applicant consents to such uses and to communication by telephone, email or mail regarding this application and related policy matters.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing false information, or conceals for the purpose of misleading, information concerning any material fact, may be subject to criminal and civil penalties under applicable law.

Consent: I authorize the insurer to obtain the records and information described above and certify that I have read and understand the statements in this Authorization, Declaration & Certification section.

Payment Authorization (Optional)

If payment by electronic transfer is authorized, provide banking information. Authorization will remain in effect until revoked in writing and shall be subject to applicable banking rules.

Authorization to Debit: I authorize debiting of amounts payable under the policy from the above account per insurer billing terms.

Final Certification

By signing below, I certify under penalty of perjury that the information provided in this application is true and complete. I agree that this application shall be the basis of any policy issued and that coverage, if granted, shall be subject to the terms, conditions and exclusions of the policy documents issued by the insurer.

Sign Now