Insurance Switch Form

INSURANCE SWITCH FORM

Applicant / Insured Information

Current Policy Details

Current Insurer:    Policy Number:

Policy Type: Auto Homeowners Life Health Commercial

Policy Period From:   To:

Requested New Policy Details

Policy Number (if known):    Requested Effective Switch Date:

Policy Type Requested: Auto Homeowners Life Health Commercial

Coverage to Be Transferred / Activated

Indicate coverages to be transferred or placed on the new policy: Liability Collision Comprehensive Personal Property Medical Payments

Beneficiary Designation (If Applicable)

Beneficiary 1:   Relationship:   Share %:

Beneficiary 2:   Relationship:   Share %:

Authorizations and Declarations

By signing below, I certify that the information provided in this Insurance Switch Form is true, complete and accurate to the best of my knowledge. I authorize my current insurer to release policy information and claim history to the proposed insurer and I authorize the proposed insurer and its representatives to obtain any records necessary to evaluate the requested switch. I understand that any material misstatement may void coverage and that premiums and underwriting requirements may change.

I hereby request cancellation of the policy identified above, effective on the cancellation date specified below, and direct my current insurer to cancel coverage on that date unless otherwise agreed in writing. I acknowledge that if there is any lapse in coverage resulting from this switch, I remain responsible for any loss during a lapse period. I release and hold harmless any insurer or agent for reliance on the representations made in this form.

Cancellation Effective Date (if different than requested switch date):

Consent to Exchange Information: I consent    Authorization to Bind Coverage Prior to Cancellation: I authorize

Exclusions and Notices

The following matters are not covered by this form: (a) any claim arising prior to the effective date of the new policy; (b) matters not disclosed on this form or in supporting documentation; (c) any coverage not expressly included on the new policy declarations. This form does not amend or alter coverage beyond the terms and conditions of the issuing insurer's policy contract.

Documentation Checklist (Attach copies)

Current policy declarations page Most recent premium payment receipt Proof of identity (government ID) Proof of ownership (if applicable) Other documentation attached

Applicant Certification

I certify under penalty of perjury and pursuant to applicable law that the statements contained in this form and the attached documentation are true and complete. I acknowledge that signature of this form constitutes my authorization for release and exchange of policy and claim information between insurers, agents, and their representatives for the purpose of effectuating the requested switch. I understand and agree that coverage becomes effective only upon issuance of a new policy by the insurer and payment of any required premium.

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