Insurance Non-Fleet Application

INSURANCE NON-FLEET APPLICATION

Applicant / Insured Information

Individual    Corporation    LLC    Partnership

Date of Birth:    Primary Contact Phone:    Email:

Policy Details

Policy Period From:    To:

Coverages Requested

Liability (Bodily Injury & Property Damage)
Collision
Comprehensive
Uninsured / Underinsured Motorist
Medical Payments
Personal Injury Protection (PIP)

Vehicle Information (List each non-fleet vehicle)

Underwriting Questions

Has the applicant had any loss, claim, or accident in the past five years?    Yes    No

Any driving convictions, suspensions or revocations in the past five years?    Yes    No

Is any vehicle listed financed or leased?    Yes    No

Exclusions / Special Conditions

The insurer reserves the right to apply exclusions, endorsements, or special conditions based on underwriting review. The applicant must disclose all known exposures and prior policy exclusions. Failure to disclose material information may result in declination or rescission of coverage.

Beneficiary / Additional Named Insured

Documentation Checklist

Please indicate which of the following are enclosed with this application:
Driver's license (all drivers)
Vehicle registration(s)
Prior policy declaration(s)
Photos of vehicle(s)
Repair/valuation estimates

Declaration and Authorization

I, the undersigned applicant, represent that the information provided in this application is true, complete and correctly recorded to the best of my knowledge. I understand that material misrepresentation, omission, or concealment of facts may give the insurer the right to deny coverage or to rescind any policy issued on the basis of this application. I agree that this application becomes part of any policy issued.

I authorize the insurer, its agents and representatives to make inquiries and obtain records from any persons, insurance companies, motor vehicle departments, employers, or medical providers regarding driving and loss history, credit-related information if applicable to underwriting, and any other relevant information necessary to evaluate this application or to administer any policy issued. I acknowledge receipt of any required fraud warnings and understand that false statements may be actionable by law.

Sign Now