Progressive Auto Insurance Policy Application

PROGRESSIVE AUTO INSURANCE POLICY APPLICATION

Applicant Information

Applicant Name:

Date of Birth:    Driver License No.:    License State:

Additional Drivers

Driver 1 Name:    DOB:

Driver 1 License No.:    Relationship:

Driver 2 Name:    DOB:

Driver 2 License No.:    Relationship:

Vehicle Information

Policy Selection and Coverage Limits

Policy Type: Liability only Collision Comprehensive Medical Payments

Liability Limits (per person / per accident):  /    Property Damage Limit:

Uninsured/Underinsured Motorist Limit:    Medical Payments Limit:

Deductible (collision/comprehensive):    Estimated Annual Premium:

Policy Period Effective Date:    Policy Period Expiration Date:

Optional Coverages

Rental Reimbursement    Roadside Assistance    GAP Insurance    Towing and Labor

Exclusions and Notices

The policy applied for will not cover losses arising from: intentional acts, use of the vehicle for unauthorized commercial activity, racing, or operation by a driver excluded under the policy. Applicant acknowledges that coverage is subject to the terms, conditions, endorsements and exclusions contained in the policy contract issued by the insurer.

I acknowledge that failure to disclose material information, including but not limited to driving history, prior accidents, or vehicle use, may void coverage or result in policy rescission. I further acknowledge that any misrepresentation made for the purpose of obtaining insurance may constitute insurance fraud under applicable law.

I acknowledge and accept the standard exclusions and notices described above.

Beneficiary for Medical/Death Benefits

Beneficiary Name:

Relationship:    Allocation Percentage:

Prior Insurance and Loss History

Have you had any accidents or violations in the past 5 years? Yes No

Declarations, Authorization and Certification

By signing below, I declare that the information provided in this application is true, complete and accurate to the best of my knowledge. I understand that the insurer will rely upon these representations in underwriting the policy. I authorize the insurer to obtain motor vehicle records, claim history and other consumer reports necessary to evaluate eligibility for coverage and premium calculation.

I understand that coverage will not be effective until the insurer completes its underwriting process and issues a policy, and that any insurance provided prior to issuance is subject to terms and conditions as determined by the insurer. I agree to notify the insurer of any material change in information provided in this application prior to policy effective date.

Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits inaccurate, false or incomplete information may be subject to civil and criminal penalties under applicable law.

I certify that I have read and understood the declarations, authorizations and fraud warning above, and I authorize the insurer to act on this application as described.

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