Insurance Personal Auto Application

INSURANCE PERSONAL AUTO APPLICATION

Applicant Information

Date of birth:    Driver's license number:    State of issuance:

Primary phone:    Email address:

Policy Details Requested

Policy type (select all that apply): Private passenger Non-owner Limited commercial use

Requested effective date:    Requested expiration date:

Bodily injury per person: $    Bodily injury per accident: $    Property damage: $

Collision deductible: $    Comprehensive deductible: $    Estimated annual premium: $

Vehicle Information (Vehicle 1)

Year:    Make:    Model:

Primary use:    Annual mileage:    Ownership status: Owned Financed/Leased

Vehicle Information (Vehicle 2)

Year:    Make:    Model:

Primary use:    Annual mileage:    Ownership status: Owned Financed/Leased

Coverage Selection

Select coverages to be included in the policy:

Prior Insurance & Loss History

Prior policy period: From To

Any accidents or claims in the last five (5) years? Yes No

Exclusions, Acknowledgements, and Endorsements

The following are standard exclusions under this application and any resulting policy unless specifically endorsed: loss due to intentional acts; use of the vehicle in an organized speed contest or racing; use of the vehicle for hire or delivery of goods where commercial coverage is not selected; operation by an excluded or unlisted driver; operation while under the influence of drugs or alcohol. Applicant acknowledges these standard exclusions by checking below.

I acknowledge the exclusions described above and understand coverage will not apply for excluded risks unless an endorsement is issued.

Beneficiary / Payee Designation (for claim payments)

Designate person or entity to receive claim settlement checks if different from applicant.

Relationship to applicant:    Percentage of proceeds: %

Declarations, Authorizations and Certifications

By submitting this application the applicant declares that all statements made in this application are true and complete to the best of the applicant's knowledge. The applicant understands that any material misrepresentation, omission or fraud may be grounds for denial of coverage or rescission of the policy and may be subject to criminal or civil penalties under applicable law.

Applicant authorizes the insurer and its representatives to obtain motor vehicle records, claim history, credit-based insurance scores, and other investigative consumer reports as needed to underwrite the application and to administer any resulting policy. Applicant further authorizes the release of claim payment to the designated payee where appropriate.

Fraud warning: Any person who knowingly submits an application containing false or misleading information may be subject to penalties, including civil or criminal prosecution and denial of benefits. Applicant certifies that no other person has an ownership interest in the vehicles listed unless disclosed above.

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