Insurance Revised Auto Form

INSURANCE REVISED AUTO FORM

Applicant / Insured Information

Date of Birth:    Driver's License Number:    State Issued:

Policy Details

Requested Effective Date:    Policy Type:

Vehicle Information — Add / Remove / Modify

Action (check one): Add Remove Modify

Purchase Date:    Lienholder Name:

If additional vehicles to be revised, attach separate sheet with same vehicle details and indicate attachment included:

Drivers to Add / Remove / Modify

Driver Action (check appropriate): Add Remove Modify

Date of Birth:    Driver License #:    State:

Relationship to Insured:    Primary Operator? Yes No

Coverage Selections and Limits

Select coverages to be applied or changed. Coverage will be effective only upon issuance of an endorsement by the insurer.

Exclusions and Conditions

The changes requested herein are subject to the insurer's underwriting review and approval. Coverage pursuant to this request will not be in force until an endorsement is issued by the insurer. Coverage shall remain subject to all terms, conditions, exclusions and limitations of the policy and any endorsements. The insurer may require additional documentation prior to issuing an endorsement.

The insurer reserves the right to deny requested changes if any material facts are omitted or misrepresented. Any willful misrepresentation, omission, or fraudulent statement in this form may render coverage void ab initio and may subject the insured to civil or criminal penalties in accordance with law.

Beneficiary / Loss Payee Information

Primary Beneficiary Name:    Relationship:    Share %:

Additional Loss Payee / Lienholder (if any):

Supporting Information

Authorization and Certification

By signing below, the undersigned certifies that all statements and answers contained in this form are true, complete and accurate to the best of the undersigned's knowledge. The undersigned acknowledges that the insurer will rely upon these statements in deciding whether to grant the requested revisions and in determining premium and terms. The undersigned understands that any materially false or misleading information may result in denial of the requested change, cancellation of coverage, or rescission of the policy.

The undersigned authorizes the insurer and its representatives to obtain motor vehicle records, claim history, and other relevant underwriting information from third-party databases and prior insurers as necessary to evaluate this request. The undersigned further authorizes release of policy change information to lienholders or loss payees as required.

Requested changes shall take effect on the requested effective date only if accepted and endorsed by the insurer. No agent, broker, or representative has authority to bind coverage or alter policy terms except as expressly stated in an issued endorsement signed by an authorized representative of the insurer.

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