Vehicle Insurance Application

VEHICLE INSURANCE APPLICATION

Applicant / Insured Information

Date of Birth:    Social Security Number (last 4):

Vehicle Information

Date Purchased:    Primary Garaging Address:

Policy Details Requested

Policy Type: Liability Only Liability + Comprehensive & Collision Comprehensive & Collision Commercial Use

Requested Policy Period Start:    End:

Coverage Selections and Options

Bodily Injury & Property Damage Liability Comprehensive (Other Than Collision) Collision Medical Payments / Personal Injury Protection Towing and Labor

Driving History / Prior Insurance

Have you had auto insurance in the past 5 years? Yes No

Additional Interest / Beneficiary / Loss Payee

Name of Lienholder / Additional Insured:

Exclusions and Important Notices

The policy applied for will contain exclusions, including but not limited to loss arising from: intentional acts or willful misconduct by the insured; use of the insured vehicle in racing or speed contests; operation of the vehicle for hire or public livery unless specifically endorsed; mechanical breakdown, wear and tear, diminution of value; and damage to property transported for a fee unless endorsed. Coverage is subject to all terms, conditions, limitations and exclusions of the policy issued.

The insurer reserves the right to decline or modify coverage based on underwriting review, including verification of statements herein, driving record, inspection of the vehicle, and motor vehicle records. Failure to disclose material information may result in denial of coverage, rescission, or cancellation of the policy.

Declarations and Authorizations

I, the undersigned, declare that the information provided in this application is true and complete to the best of my knowledge. I understand that any deliberate misrepresentation or material omission of fact may void coverage and may be grounds for policy rescission or denial of claims. I agree that this application shall form the basis of any policy issued.

I authorize the insurer, its agents and representatives to obtain and verify motor vehicle records, claim history, credit information where permitted by law, and any other information necessary to underwrite, service, or renew my policy. I authorize prior insurers and other sources to release such information to the insurer.

I understand that coverage, premiums, and terms are subject to applicable statutes and company underwriting rules. I acknowledge receipt of the Fraud Notice applicable to my state, and I understand that submission of false information may constitute insurance fraud under applicable law.

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