Insurance Signature Apps

INSURANCE SIGNATURE APPS

Applicant / Insured Information

Applicant Name:

Insured Name (if different):

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

Entity Type: Individual Corporation Partnership Trust

Policy Details

Policy Type:

Policy Period Start:    End:

Coverage Selection

Select coverages requested (coverage will be subject to underwriting approval and policy terms):

Liability

Property

Collision

Comprehensive

Medical Payments

Uninsured / Underinsured Motorist

Exclusions

The policy will include standard exclusions. Indicate any additional exclusions requested. All exclusions must be expressly listed on the policy declarations to be effective.

Wear and tear / deterioration

Intentional loss or fraudulent acts

War, nuclear hazard

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Percentage:

Relationship:    Percentage:

Declarations, Authorizations & Certifications

I certify that all information provided in this application is true, complete and accurate to the best of my knowledge. I understand that the insurer may rescind coverage, deny claims or void the policy if material misstatements, omissions, or fraudulent statements are discovered.

I authorize the insurer, its representatives, and my agent or broker to obtain and review underwriting, claims, loss history, credit, and other information necessary to evaluate this application. I authorize release of such information from prior insurers, employers, medical providers (if applicable) and other repositories of relevant information. A photographic or electronic copy of this authorization shall be as valid as the original.

I acknowledge that coverage, limits, and terms are set forth in the policy contract and that no agent, broker, or applicant has authority to bind coverage or alter policy terms except as set forth in a written policy or endorsement issued by the insurer. Premium payment does not guarantee coverage unless expressly accepted by the insurer.

Fraud Warning: Any person who knowingly presents false information, or conceals a material fact, in order to obtain insurance may be subject to civil and criminal penalties under applicable law, including denial of coverage and recovery of benefits paid.

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