Insurance Policy Choice

INSURANCE POLICY CHOICE

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Selection

Select the type(s) of policy you elect to purchase (check all that apply):

Auto (Personal Automobile)
Homeowners
Renters
Life
Health
Other:

Policy Effective Date:    Policy Expiration Date:

Coverage Options

Choose coverages and specify limits or deductibles where applicable.

Liability Coverage Limit: $

Collision Coverage Deductible: $

Comprehensive Coverage Deductible: $

Personal Property / Contents Limit: $

Medical Payments Limit: $

Premium, Payment and Deductible

Annual Premium: $    Payment Frequency:

Initial Deposit / First Payment: $

Exclusions and Acknowledgments

The following are common exclusions under the selected coverage(s). This list is representative and not exhaustive:

• Intentional acts, fraud, or criminal conduct by the insured.
• Normal wear and tear, gradual deterioration, and defects in workmanship or materials.
• Losses arising from war, nuclear hazard, or government seizure where excluded by the policy.
• Certain high-risk activities or uses specifically identified in policy exclusions.

I acknowledge that I have read and understand the exclusions that may apply to the selected policy options and that final policy terms, conditions, and exclusions will be set forth in the issued policy form.

Beneficiary Designation (If Applicable)

Beneficiary Name:

Relationship to Insured:    Percentage of Benefit: %

If multiple beneficiaries are named, attach additional sheet with full name, relationship, and percentage allocations summing to 100%.

Declarations and Certification

By signing below, Applicant certifies that all information provided on this Insurance Policy Choice form is true, complete, and submitted with the intent that it be relied upon by the insurer in issuing coverage. Applicant understands that any material misrepresentation or omission may result in denial of coverage, rescission of the policy, or other remedies available under the policy and applicable law.

Applicant further acknowledges and agrees that: (a) coverage is subject to payment of premiums and to the terms, conditions, limitations and exclusions contained in the policy; (b) selection of coverage options on this form is an election and will be reflected in the issued policy documents; and (c) the insurer reserves the right to underwrite, modify or decline coverage based on underwriting review.

Applicant authorizes the insurer and its representatives to obtain such information as reasonably necessary to underwrite, issue and administer this policy, including consumer reports where permitted by law.

I consent to electronic delivery of policy documents and notices where permitted by law.

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