Insurance No-Fault Application

INSURANCE NO-FAULT APPLICATION

Applicant / Insured Information

Policy Details

Policy Type:   Policy Number (if known):

Policy Period: From to

Vehicle / Exposure Information

Coverage Options and Limits

Select the coverage options you request (check all that apply). Selections are subject to underwriting approval and applicable state law.

Medical Expense Coverage - PIP $25,000    Medical Expense Coverage - PIP $50,000    Medical Expense Coverage - PIP $100,000

Wage Loss Coverage (percentage of gross weekly wage)    Death Benefit / Funeral Expense Coverage

Beneficiary Designation (Death Benefit)

Designate beneficiary(ies) to receive death benefits under the no-fault coverage. If no beneficiary is designated, benefits will be paid in accordance with applicable law.

Exclusions and Limitations

The following are examples of material exclusions under no-fault coverages. This list is not exhaustive. Coverage will be subject to the policy terms, conditions and applicable law.

- Injuries sustained while committing a criminal act or intentionally caused by the insured.
- Injuries occurring while the insured is operating a vehicle while legally intoxicated or under the influence of controlled substances, unless otherwise permitted by law.
- Losses arising from war, nuclear hazard, or governmental seizure.
- Bodily injury to operators or occupants of excluded vehicles or non-listed drivers, except as required by statute.
- Claims for services not reasonably related to the treatment of the covered bodily injury, including cosmetic procedures, experimental treatments, or pre-existing conditions unrelated to the covered loss.

Prior Insurance and Claims History

Yes    No

Documentation Checklist (For Claims)

For prompt handling of future claims, provide copies of available documents at the time of claim filing:

Police report (if applicable)
Itemized medical bills and receipts
Medical records and treating provider statements
Proof of loss / accident report
Wage verification for wage loss claims

Declarations, Authorizations and Certifications

By signing this application, the applicant certifies that the information provided is true, complete and correct to the best of their knowledge. The applicant understands that material misrepresentation or omission of fact may result in denial of coverage or rescission of the policy, and may subject the applicant to civil or criminal penalties under applicable law.

The applicant authorizes any physician, medical provider, hospital, employer, insurer, or other entity to release medical records, wage records, and other relevant information to the insurer or its agents for the purposes of underwriting, claim investigation, payment, and defense of claims. A copy of this authorization shall be as valid as the original.

The applicant hereby assigns to the insurer any rights to recover medical payments or wage benefits from third parties to the extent the insurer has provided payment under the policy, subject to policy terms and state law.

The applicant acknowledges receipt of the insurer's notice regarding fraud prevention and acknowledges that knowingly submitting false information may constitute insurance fraud.

Authorization to Bind Coverage and Payment

Submission of this application does not bind coverage. Coverage becomes effective only upon issuance of a policy and receipt of the required premium, unless otherwise agreed in writing by the insurer. The applicant authorizes the insurer to initiate premium billing and to charge the applicant's indicated payment method upon policy issuance.

Applicant certifies that they have read and understand the terms set forth in this application and that they accept the insurer's right to verify information provided herein.

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