Insurance Policy Quote Form

INSURANCE POLICY QUOTE FORM

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:

Existing Policy Number:    Expiration Date:

Policy Details Requested

Requested Policy Type: (select all that apply)

Automobile    Homeowners    Renters    Life    Commercial

Liability    Collision    Comprehensive    Personal Injury Protection

Uninsured/Underinsured Motorist    Property Damage    Medical Payments

Requested Policy Period Start:    End:

Loss History and Underwriting Details

Yes    No

Exclusions and Limitations

The quote provided is subject to written policy terms, conditions, endorsements and exclusions. Standard exclusions include, but are not limited to: intentional acts, fraudulent acts, nuclear hazard, war and military action, wear and tear, and loss arising from unlawful transfer or use. Applicant acknowledges that a final binding policy is issued only upon payment of premium and completion of underwriting.

I acknowledge receipt of and understand the foregoing exclusions and limitations:    Applicant initials acceptance

Beneficiary Designation (if applicable)

Primary Beneficiary Name:

Relationship:    Percentage:

Contingent Beneficiary Name:

Agent / Producer Information

Declarations and Certification

By submitting this form, the applicant represents that all information provided is true, complete and correct to the best of their knowledge. Applicant authorizes the insurer and its representatives to obtain and verify information necessary for underwriting, including motor vehicle records and claim history. Applicant understands that this form is an application for a quote only; it does not bind coverage. A binding policy will be issued only upon acceptance by the insurer and receipt of any required premium payment and issuance of a policy document.

Applicant warrants that no material facts have been withheld. Any misrepresentation or omission of material facts may permit the insurer to rescind the coverage or deny claims where permitted by law. Applicant agrees that the insurer may rely on electronic signatures and representations provided on this form for the purpose of issuing a quote and policy.

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