Insurance Quote Application

INSURANCE QUOTE APPLICATION

Applicant Name:   Date of Birth:   SSN (last 4):

Policy Details Requested

Policy Type (select all that apply): Auto Homeowners Renters Life Commercial Umbrella

Coverage Options

Select coverage options requested:

Risk and Property / Vehicle Information

If Auto: Year/Make/Model:   VIN:

Prior Coverage & Loss History

Any claims, losses, or incidents in the past 5 years? Yes No

Documentation Checklist for Quote

Provide copies of the following as available. Check items attached or to be provided:

Beneficiary (if applicable)

Exclusions and Important Notices

The quote provided by the Insurer is subject to underwriting review, verification of the information supplied, and acceptance of required documentation. Estimated premiums are non-binding until a policy is issued in writing. The following are typical exclusions that may apply and do not constitute a complete list of exclusions:

• Intentional acts, fraud, or criminal activity by the insured;
• Damage or loss caused by wear and tear, gradual deterioration, or lack of maintenance;
• Damage arising from war, nuclear hazard, or government action unless specifically endorsed;
• Certain flood or earthquake losses unless a specific endorsement or separate policy is purchased;
• Business activities or professional services not disclosed and accepted by the Insurer.

By signing below, Applicant certifies that the information provided in this application is true and complete to the best of Applicant's knowledge. Applicant authorizes the Insurer and its agents to obtain and verify information about Applicant, including motor vehicle records, prior insurance and claims history, credit reports, loss runs, and other underwriting information as permitted by law. Applicant acknowledges that any material misstatement or omission may be the basis for denial of coverage or rescission of the policy.

Applicant further acknowledges that submission of this form is an application for a quote only and does not bind coverage. Coverage will be effective only upon issuance of a policy or binder by the Insurer and receipt of any required premium. Applicant agrees to cooperate with the Insurer in the underwriting process and to provide additional documentation as requested.

Fraud Warning

Any person who knowingly presents a false or fraudulent claim for payment of a loss or any person who knowingly presents false information in an application for insurance may be guilty of a crime and subject to fines and confinement in accordance with applicable law.

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