Insurance Sign Packet

INSURANCE SIGN PACKET

APPLICANT / INSURED INFORMATION

Applicant Name:

Date of Birth:    Social Security Number (last 4):

PROPOSED POLICY DETAILS

Policy Number (if renewing):

Proposed Policy Period From:    To:

COVERAGES (Select applicable)

Liability Coverage     Property Coverage     Collision Coverage

Comprehensive Coverage     Medical Payments     Uninsured/Underinsured Motorist

EXCLUSIONS & ACKNOWLEDGEMENTS

The following items are examples of common policy exclusions: intentional acts, fraudulent acts, wear and tear, war, nuclear hazard, and perils specifically excluded in the policy declarations. Applicant acknowledges receipt and review of the proposed exclusions and understands coverage is limited to risks expressly described in the policy contract.

Applicant acknowledges and accepts the stated exclusions and understands that coverage is subject to the policy terms.

BENEFICIARY DESIGNATION

Primary Beneficiary Name:

PRIOR LOSS / CLAIM HISTORY

Have you had any claims or losses in the past five years?   Yes    No

PAYMENT AUTHORIZATION

Preferred Payment Method:

Annual Check    Credit/Debit Card    Bank Draft (ACH)

By signing this packet, applicant authorizes the insurer to initiate premium charges in accordance with the payment method selected. Applicant warrants authority over the provided payment instrument and agrees that returned payments or insufficient funds may result in policy cancellation in accordance with the policy terms.

AUTHORIZATION & RELEASE

I certify that the information provided in this packet is true, complete, and accurate to the best of my knowledge. I authorize the insurer, its agents and representatives to obtain, verify and exchange information concerning my insurability, loss history, and claims, including but not limited to consumer reports and motor vehicle records, as permitted by law. This authorization remains valid for the duration of any policy issued on the basis of this application and for a reasonable period thereafter for purposes of underwriting, claims handling and fraud investigation.

I understand that misrepresentations or omissions of material facts may be grounds for denial of coverage or rescission of the policy. I further understand that any policy issued will be governed by the policy contract, endorsements, and applicable law.

Applicant hereby provides authorization and consents to the statements above.

ELECTRONIC DELIVERY & RECORDS CONSENT

I consent to receive policy documents, endorsements, billing notices, and correspondence electronically where permitted. I understand I may withdraw consent for electronic delivery as provided in policy procedures, but withdrawal will not affect the validity of prior electronic communications.

Applicant consents to electronic delivery of policy and billing documents.

FRAUD WARNING

Any person who knowingly presents false information in an application for insurance may be subject to criminal and civil penalties under applicable law. Applicant certifies that all statements made in this application are true, complete and made without omission of material fact.

CLAIMS REPORTING ACKNOWLEDGMENT

In the event of a loss, the insured must notify the insurer promptly and cooperate with reasonable requests to document and investigate the claim. Failure to report within the time period required by the policy may prejudice coverage.

Applicant acknowledges claims reporting obligations under any issued policy.

DECLARATION AND CERTIFICATION

By signing below, I declare under penalty of perjury that the foregoing statements and answers are true and complete. I understand that the insurer will rely on this information in determining my eligibility for insurance and the terms of any policy issued. I agree to promptly notify the insurer of any material changes to the information contained herein.

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