Insurance Renters Auto Application

Insurance Renters Auto Application

Applicant / Insured Information

Residence & Occupancy

Residential status (select one): Renter Owner Other

Vehicle Information (Vehicle 1)

Additional Vehicle (Optional)

Drivers to be Insured

Has any driver to be insured had a license suspension, conviction for DUI/DWI, or any major violation within the past five (5) years? No Yes — If yes, provide details below.

Insurance History & Claims

Any accidents or claims in the past five (5) years? No Yes

Policy Selections & Coverage

Select desired coverages and indicate limits or deductibles where applicable. Selections are subject to underwriting approval and binding requirements of the insurer.

Liability Coverage    Limits:

Collision Coverage    Deductible:

Comprehensive Coverage    Deductible:

Uninsured / Underinsured Motorist    Limit:

Medical Payments    Limit:

Rental Reimbursement    Per Day: Max Days:

Roadside Assistance    Limit:

Policy Period, Premium & Payment

Preferred Payment Method: Electronic Funds Transfer (EFT) Credit/Debit Card Check

Exclusions & Important Notices

The coverage requested does not apply to losses arising from: intentional acts by the insured; operation of a vehicle for hire or delivery when not disclosed and rated; use of the vehicle in a racing or speed contest; damage due to normal wear and mechanical breakdown; nuclear hazard, war, or confiscation by authorities. Coverage may be excluded for an excluded driver, for a vehicle used in the commission of a felony, or where operation is contrary to the terms of the policy.

I acknowledge that I have read and understand the typical exclusions described above and that any additional exclusions applicable to the policy will be stated in the policy language provided at binding. Applicant acknowledges exclusions

Beneficiary / Payee Designation

Designate one payee for refund or proceeds in the event of the insured's demise or policy refund. (If no designation provided, proceeds will be payable pursuant to policy and applicable law.)

Declaration, Authorization & Certification

By signing below, the applicant certifies that all information provided in this application is complete, true and accurate to the best of the applicant's knowledge. The applicant understands that any material misrepresentation, omission, or false statement may result in denial of coverage, rescission of the policy, or denial of a claim.

The applicant authorizes the insurer and its agents to obtain and verify motor vehicle records, prior claims history, credit information where permitted by law, and any other information necessary for underwriting and claim handling. The applicant authorizes third parties to release requested information to the insurer and its agents for these purposes.

Fraud Warning: Any person who knowingly presents false information in an application for insurance or who knowingly submits false statements or false documents in support of a claim may be guilty of insurance fraud and subject to civil and criminal penalties under applicable law.

Applicant certifies that they have disclosed all drivers and vehicles to be insured and will promptly notify the insurer of any material changes in the risk, including change of principal garaging address, change in primary operator, addition of regular operators, or the initiation of commercial use of the vehicle.

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