Van Insurance Application Form

Van Insurance Application Form

Applicant / Insured Information

Applicant Name:

Date of Birth:    Driver's License No.:

Vehicle Information

Year:    Make:    Model:

License Plate:    State:    Odometer (mi):

Personal / Pleasure    Commuting to/from work    Business use (non-commercial)    Commercial / For-hire / Delivery

Policy Details Requested

Liability Only    Comprehensive    Collision    Uninsured / Underinsured Motorist

Requested Effective Date:    Requested Term (months):

Bodily Injury per Person:    Bodily Injury per Accident:

Property Damage:    Comprehensive Deductible:    Collision Deductible:

Driver Information (Primary Driver)

Driver Name:    Relationship to Applicant:

Driver Date of Birth:    Driver's License State:    Years Licensed:

Any accidents or claims: Yes    No

Prior Insurance / Loss History

Previous Policy Number:    Coverage Dates: From to

Yes    No

Coverage Options & Add-Ons

Rental Reimbursement:    Roadside Assistance:    Replacement Cost Coverage:

Exclusions

The policy applied for will not provide coverage for: intentional acts or willful misconduct; use of the vehicle for illegal activities; operation by an unlisted or excluded driver; normal wear and tear, mechanical or electrical breakdown; use as a public or livery conveyance unless declared and endorsed; war, nuclear incident, or government requisition; any loss excluded by endorsement issued at policy inception. Any material misrepresentation or omission in this application may result in rescission or denial of claims.

Loss Payee / Additional Interest

Documentation Checklist

Please attach or provide copies of the following as applicable (check box to indicate enclosed):
Driver's license copy    Vehicle registration    Prior policy declaration page    Photos of vehicle condition    Police report (if applicable)

Declaration and Authorization

I hereby declare that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation or omission may be grounds for denial of coverage or rescission of the policy. I authorize the insurer and its representatives to obtain motor vehicle reports, claims history, credit information, and other underwriting data necessary to evaluate this application. I agree that this application, together with any supplemental information and inspection reports, shall form the basis of the insurance contract if a policy is issued.

I understand and acknowledge that coverage will not be in force until a policy is issued and premium received by the insurer or its authorized agent. Submission of this application does not bind coverage unless specifically agreed in writing by the insurer.

Warning: Any person who knowingly provides false, incomplete or misleading information for the purpose of defrauding an insurer may be guilty of insurance fraud and subject to civil or criminal penalties under applicable law.

Sign Now