Insurance Policy Form Application

INSURANCE POLICY APPLICATION

Use this form to apply for issuance of an insurance policy. Complete all sections accurately and sign the declaration at the end. The information provided herein will form the basis of any policy issued and is subject to verification. Misrepresentation or omission of material facts may result in denial of coverage or rescission of the policy.

1. Applicant / Insured Information

2. Policy Details

Requested Policy Type (select all that apply):

Homeowners Auto Life Commercial General Liability Professional Liability Other

Additional coverages requested (select all that apply):

Flood Earthquake Medical Payments Personal Injury Protection Uninsured Motorist Roadside Assistance

3. Risk Details

4. Claims History

Have you or any proposed insured had any losses or claims in the past 5 years?

Yes No

5. Beneficiary Designation (if applicable)

6. Documentation Checklist

Provide copies of applicable documents with this application (check those included):

Proof of Identity
Proof of Ownership / Title
Vehicle Registration
Medical Records (if required)
Photographs of Property / Damage
Repair / Replacement Estimates

7. Exclusions and Limitations

The policy applied for will contain exclusions, conditions and limitations. Typical exclusions include but are not limited to loss caused by intentional acts, wear and tear, nuclear hazard, war, and government action. Coverage for certain perils such as flood and earthquake is not automatic and must be expressly requested and endorsed. The insurer reserves the right to apply sublimits, deductibles, and special terms.

I acknowledge that I have read and understand that exclusions and limitations will apply to any policy issued and that premiums and terms are subject to underwriting review and may be modified or declined based on the information provided.

I acknowledge and accept the existence of exclusions and limitations as described above.

8. Declarations and Authorization

By signing this application I declare that the statements and particulars contained in this application and any attachments are true and complete to the best of my knowledge and belief. I agree that this application, together with any attachments and any statements made by me in support of this application, shall form the basis of and be deemed incorporated into any policy issued by the insurer.

I authorize the insurer and its representatives to make any inquiries, obtain records, and conduct inspections as necessary to evaluate this application and to verify the information provided. I understand that coverage may be contingent upon the satisfactory completion of underwriting, receipt of required documents, and payment of premium.

I acknowledge that any fraudulent or intentionally false statement made for the purpose of obtaining insurance is a crime and may result in criminal prosecution, denial of coverage, or policy rescission.

9. Authorization for Premium Payment

Payment of premium binds coverage only when accepted by the insurer. Failure to pay premium when due may result in cancellation of coverage in accordance with the policy terms. Applicant authorizes the insurer to process premium payment as agreed in any separate premium payment agreement.

10. Applicant Certification and Signature

I certify under penalty of perjury that the information contained in this application is true, correct and complete. I understand and agree that the insurer may retain this application whether or not the policy is issued and that a copy of this application shall have the same force and effect as the original.

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