Insurance Signed Form

INSURANCE SIGNED FORM

Applicant / Insured Information

Policy Details

Policy Number:    Policy Type: Auto Homeowners Life Health Other

Policy Period: Effective through .

Coverage Selection

Select coverages to be included in this policy (initial all that apply and provide any required details).

Liability Coverage

Collision Coverage

Comprehensive Coverage

Medical Payments / Personal Injury Protection

Uninsured / Underinsured Motorist

Exclusions and Limitations

The Insurer shall not be liable for loss or expense resulting directly or indirectly from war, nuclear hazard, intentional acts, fraudulent acts by the Insured, or any loss specifically excluded in applicable endorsements. The following specific exclusions apply unless expressly added by endorsement: wear and tear, mechanical breakdown, intentional damage, loss from unlawful acts by the insured, and losses arising from use of the insured property for commercial rental unless agreed in writing.

Acknowledgement of Standard Exclusions: I acknowledge and understand the standard exclusions set forth above and any referenced endorsements.

Beneficiary Designation (if applicable)

Primary Beneficiary Name: Relationship: Percentage:

Contingent Beneficiary Name: Relationship: Percentage:

Prior Claims and Loss History

Have you had any claims or losses in the past five (5) years? Yes No

Payment and Authorization

Payment Method:

Authorization to Charge Premium: I authorize the insurer to charge premiums as indicated and to apply payments to my policy in accordance with premium due dates and billing terms.

Declarations, Certifications, and Notices

By signing below, the Applicant certifies that all statements and answers contained in this Insurance Signed Form are true, complete and made for the purpose of obtaining insurance. The Applicant understands that any materially false statement or omission may be grounds for denial of coverage, rescission of the policy, or denial of a claim, and may subject the Applicant to civil or criminal penalties under applicable law. The Applicant authorizes the Insurer to obtain and verify information about the Applicant, including but not limited to loss history, credit information where permitted by law, and medical or claims records when relevant to the coverage applied for.

The Applicant acknowledges receipt of the policy terms, declarations, and applicable endorsements upon issuance. Cancellation, non-renewal, and premium changes will be effected in accordance with the policy provisions and applicable law. Coverage is contingent upon acceptance by the Insurer and receipt of the required premium payment unless otherwise agreed in writing.

Arbitration and Dispute Resolution: Any dispute arising out of or relating to this policy or the application shall, at the election of either party, be submitted to binding arbitration in accordance with the arbitration rules selected by the Insurer, except where prohibited by law. The prevailing party shall be entitled to recover reasonable attorneys' fees and costs where permitted by law.

Fraud Notice: It is unlawful and a material misrepresentation to intentionally conceal or misrepresent any fact or circumstance relating to this application. Such misrepresentation may result in denial of coverage or cancellation of the policy, in addition to other remedies available to the Insurer.

Applicant Affirmation: I affirm that the information provided in this Insurance Signed Form is accurate to the best of my knowledge and I consent to the terms and authorizations contained herein.

Sign Now