Insurance Policy Quote

INSURANCE POLICY QUOTE

Insurer and Quote Identification

Insurer Name:

Quote Reference Number:

Applicant / Insured Information

Date of Birth:   Tax ID / SSN (last 4 digits only):

Policy Details and Premium Estimate

Policy Type (select all that apply):

Auto    Homeowners    General Liability    Professional Liability    Commercial Property    Umbrella

Coverage Options and Endorsements

Select requested coverages and indicate limits where applicable.

Bodily Injury Liability — Limit:

Property Damage Liability — Limit:

Comprehensive (if auto)    Collision (if auto)    Uninsured/Underinsured Motorist

Flood Coverage Endorsement    Earthquake Endorsement    Rental Reimbursement / Business Interruption

Premium Calculation (Estimated)

Base Premium:

Policy Fee:   Taxes and Surcharges:

Total Estimated Annual Premium:

Exclusions and Limitations

The following exclusions are typical to the quoted coverage. The final policy, if issued, will contain the complete terms, conditions and exclusions. Applicant acknowledges that the quote does not expand coverage beyond the terms of the issued policy.

• Loss caused by war, nuclear incident, or governmental action is excluded unless specifically endorsed.
• Losses resulting from intentional acts or fraudulent conduct by an insured are excluded.
• Wear and tear, gradual deterioration, and maintenance items are excluded.
• Flood and earthquake are excluded unless a corresponding endorsement is selected and premium is paid.

I acknowledge that I have reviewed the common exclusions and understand that additional exclusions and conditions appear in the policy form that will be issued if coverage is bound. Acknowledged

Beneficiary / Additional Insured

Underwriting and Risk Questions

In the last 5 years, has the applicant had any insurance claims or losses?    Yes    No

Has any insurer declined, cancelled or refused renewal of coverage for the applicant in the past 5 years?    Yes    No

Payment and Binding Instructions

Premium payment options (select one):

Annual    Semi-Annual    Monthly Installments    Electronic Funds Transfer (EFT)

Binding instructions: Coverage will become effective only upon receipt of any required down payment and execution of a formal policy by the insurer. This quote is an estimate only and does not bind coverage. Underwriting verification and documentation may change premium, terms, or eligibility.

Certification and Authorization

By signing below, the applicant certifies that the information provided in this quote request is true and complete to the best of the applicant's knowledge. The applicant understands that any material misrepresentation or omission may be a basis for denial of coverage or rescission of any policy issued.

The applicant authorizes the insurer and its agents to obtain underwriting information including loss history, credit-based insurance scores, and any other information reasonably required for underwriting and rating. This authorization extends to any consumer reporting agency or prior insurer.

This quote is valid for a period of days from the date issued, unless otherwise withdrawn in writing by the insurer.

Acknowledgment

I acknowledge receipt of this Insurance Policy Quote and understand that it is an estimate and not a policy. Final coverage, terms, exclusions and premium will be determined by the insurer's underwriting and as set forth in the issued policy documents.

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