Insurance Service Application

INSURANCE SERVICE APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth:   Tax ID / SSN (last 4):

Policy Details

Policy Type (select all that apply):

Auto Homeowner Renter Life Commercial Other:

Policy Period: From to

Coverage Options

Select desired coverage components and indicate limit where applicable:

Exclusions and Limitations

The proposed policy, if issued, will contain exclusions, limitations, and conditions including but not limited to: intentional acts, normal wear and tear, mechanical breakdown (except as specifically endorsed), losses arising from war or nuclear hazard, and punitive or exemplary damages where prohibited by law. The insurer reserves the right to amend or add exclusions based on underwriting information and investigation.

I acknowledge that I have read and understand that exclusions and limitations will apply to any policy issued.

Do any premises or insured items involve hazardous materials, underground storage, or operations regulated for environmental risk? Yes No

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Percentage:

Prior Coverage & Claims History

Previously insured in the last 5 years? Yes No

Any claims in the last 5 years? Yes No

Required Documentation Checklist

Please attach or indicate availability of the following documents:

Declarations and Certification

By submitting this application I certify that the information provided in this application and any attachments is true, complete and accurate to the best of my knowledge. I understand that material misrepresentation or omission of facts may give rise to denial of coverage, cancellation of any policy issued, or rescission as permitted by law. I authorize the insurer, its agents, reinsurers, and representatives to obtain and verify information relevant to this application, including but not limited to motor vehicle records, claims history, credit information, and other consumer reports as permitted by law.

I understand that completion of this application does not bind coverage. Coverage, limits, premiums, and policy terms will be set forth in a policy document issued by the insurer. I agree to promptly notify the insurer of any material changes in the facts set forth in this application prior to issuance of a policy.

I authorize the insurer to obtain consumer reports and claim history information for underwriting and claim purposes, and to make such disclosures as required to reinsurers and as permitted by law.

Additional Information

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