Insurance Premium Application

INSURANCE PREMIUM APPLICATION

Applicant / Insured Information

Date of Birth:    Occupation:

Individual Corporation LLC Partnership

Policy Details

Policy Type: Auto Homeowners Renters General Liability Professional Liability Commercial Property

Effective Date:    Expiration Date:

Monthly Quarterly Annually

Coverage Selections

Select coverages requested and indicate limit / deductible where applicable.

Property Coverage — Limit: Deductible: Liability Coverage — Limit: Comprehensive Coverage — Deductible: Collision Coverage — Deductible: Uninsured Motorist Coverage — Limit: Medical Payments — Limit:

Exclusions and Limitations

The policy, if issued, will include standard exclusions including but not limited to: intentional acts, war and civil commotion, nuclear hazard, wear and tear, pollution not otherwise covered, and theft where reasonable safeguards are not maintained. Additional exclusions specific to policy type may apply.

By checking the box below the applicant acknowledges that they have read and understand that exclusions and limitations may reduce or eliminate coverage for particular losses.

I acknowledge I have read and understand the exclusions and limitations that may apply to the policy.

Beneficiary Designation

Primary Beneficiary Name:    Relationship:    Percentage:

Contingent Beneficiary Name:    Relationship:    Percentage:

Claims History

Have you, or any person proposed for coverage, had any claims or losses in the past five (5) years?   Yes No

Documentation Checklist

Please attach or indicate documents provided with this application:

Valid government-issued photo ID Photographs of property / vehicle Police report (if applicable) Repair or replacement estimates Prior policy declarations (if renewal)

Premium Calculation & Payment

Credit Card (provide last 4 digits) Bank Transfer (provide last 4 of routing/account) Check

Payment Authorization: I authorize the insurer or its agent to initiate payment transactions as selected above and agree that premiums must be paid when due. I understand nonpayment may result in cancellation or nonrenewal.

Declaration and Certification

I certify that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that this application forms the basis for any policy issued and that material misrepresentation, omission, or concealment of facts may result in denial of coverage, rescission, or voiding of the policy. I authorize the insurer to obtain and exchange underwriting and claims information, including reports from other insurers, and to make any inquiries necessary to evaluate this application.

I understand that completion of this application does not bind the insurer to provide coverage. Coverage will only be effective upon issuance of a policy and receipt of payment as specified by the insurer. Where applicable, I consent to the electronic delivery of policy documents and notices.

The applicant acknowledges that premium quotations are estimates and final premium will be determined by the insurer following underwriting review. Any binder issued pending underwriting is subject to the terms, conditions, and exclusions of the binder and the policy that may later be issued.

Certification: By signing below I represent that I am authorized to provide the information contained in this application and to execute this application on behalf of the person(s) or entity proposed for insurance.

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