Insurance Vehicle Request Form

INSURANCE VEHICLE REQUEST FORM

I. Applicant / Insured Information

Applicant Name:

II. Driver's License & Prior Insurance

III. Policy Details Requested

Existing Policy Number (if applicable):

Requested Coverage Types (select all that apply):

Liability    Collision    Comprehensive    Uninsured/Underinsured Motorist

Personal Injury Protection    Medical Payments    Rental Reimbursement    Roadside Assistance

Requested Policy Period: From to

IV. Vehicle Information

V. Additional Drivers and Vehicle History

VI. Attachments Checklist

Copy of vehicle registration

Proof of prior insurance (declaration page)

Copy of driver's license

Photos of vehicle (front, rear, VIN plate)

Financing / lien agreement (if applicable)

VII. Exclusions & Special Conditions

The applicant acknowledges that coverage will be subject to the insurer's policy language, endorsements and specific exclusions which may include, without limitation, racing, intentional acts, use of the vehicle for hire where not declared, and use by unlisted drivers. Applicant must disclose all material facts and the insurer may decline or rescind coverage for material misrepresentation.

I acknowledge the potential exclusions and special conditions described above and accept that final coverage determination will be made by underwriter.

VIII. Beneficiary / Loss Payee (if applicable)

IX. Declarations, Authorizations and Fraud Notice

I certify that the information provided in this Insurance Vehicle Request Form is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation, omission, or concealment of fact may result in denial of coverage or rescission of any policy issued based on this request. I understand that coverage is not effective until a policy is issued and any required premium is paid, and that the insurer may underwrite or decline this request after review.

I authorize the insurer and its authorized representatives to obtain motor vehicle records, driving history, claims history, and other consumer reports as required to evaluate this request and to disclose information to other insurers, agents, and entities with a legitimate business need for underwriting, claims, or fraud prevention. I further authorize any person or entity to release such information upon request.

Fraud Warning: Any person who knowingly submits false information or conceals material facts with the intent to defraud may be subject to civil and criminal penalties under applicable law.

By checking this box I consent to the authorizations above and declare that the statements in this application are accurate.

X. Additional Instructions / Underwriting Notes

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