Renters and Auto Insurance Application

Renters and Auto Insurance Application

Applicant Information

Applicant Name:

Date of Birth:    Social Security / Tax ID:

Co-Applicant / Additional Driver (if applicable)

Residence and Tenancy

Years at current residence:    Residence type: Owned Rented Other

Auto Insurance — Vehicle Details (list each vehicle)

VIN:    Year:

Primary use:    Annual mileage:

Add additional vehicles? Vehicle 2 Vehicle 3

Insurance History and Claims

Current or most recent insurer:    Policy number:

Prior claims or accidents in past 5 years? Yes No

Coverage Selection — Renters

Personal property coverage (limit): $    Personal liability limit: $

Deductible: $    Additional living expense coverage: Requested

Coverage Selection — Auto

Bodily injury/property damage liability limits (per occurrence):

Comprehensive deductible: $    Collision deductible: $

Optional coverages (check all requested):
Uninsured/Underinsured Motorist    Rental Reimbursement    Towing and Labor

Policy Details & Premium

Requested policy effective date:    Requested policy expiration date:

Payment plan: Annual    Monthly    Installments

Exclusions and Important Notice

The coverages applied for are subject to the insurer's policy forms, conditions, endorsements and exclusions. Typical exclusions include but are not limited to: intentional acts, wear and tear, nuclear hazard, war, certain high-risk recreational use, and business use of personal autos without prior underwriting. Acceptance of this application is subject to underwriting review, verification of information, and payment of required premium.

Beneficiary / Payee for Personal Property (Optional)

Beneficiary Name:

Relationship:    Percentage:

Documentation Checklist

Please provide copies of the following at application submission (check provided items):
Driver's license / ID    Proof of residence    Prior policy declarations
Vehicle photos    High-value personal property photos

Declarations, Authorization and Signature

I declare that the statements on this application are true and complete to the best of my knowledge. I understand that any material misrepresentation, omission or incorrect statement may be the basis for rescission of coverage or denial of claims. I authorize the insurer, its agents, and authorized representatives to obtain and verify information relevant to underwriting and claims including motor vehicle records, prior insurance and claims history, credit information where permitted by law, and other consumer reports. I consent to the release of information to other insurers or agencies for claim investigation and fraud detection. I understand that coverage is not effective until accepted and issued by the insurer and required premium is paid.

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