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Filling out an automobile insurance application form is a significant step in securing the right coverage for your vehicle and drivers. This comprehensive document typically includes several key sections designed to gather essential information about the insured individuals, driving history, and vehicle specifications. Personal information, such as the name and address of each insured party, is required upfront, along with additional details about co-applicants. The form also necessitates the completion of driver information for each individual to be insured, including their marital status, gender, birth date, and driving license details. Vehicle specifics follow, where you will note the Vehicle Identification Number (VIN), make and model, and annual mileage for each car you wish to cover. It's important to outline how each vehicle will be used, whether for business or leisure, and to disclose any safety features or anti-theft devices installed. Current insurance information and a comprehensive driving history section detailing any accidents or violations over the past 36 months also play crucial roles in the application process. An information release form is typically included, giving insurers the authority to access pertinent reports that may affect your coverage eligibility. Throughout this application, accuracy is vital, as any discrepancies may lead to issues with coverage later on.

Automobile Insurance Application Example

Personal Automobile Insurance Application

Allen Financial Insurance Group • 800-874-9191 • FAX: 602-992-8327 • www.EQGroup.com

Please fax completed application along with the declarations page(s) of your current policy

INSURED INFORMATION

Name:

 

Name of co-applicant:

 

 

 

Address:

 

City:

 

 

 

County:

State:

Zip: Rent/Own:

 

 

 

Home Phone Number:

 

Business Phone Number:

 

 

 

Email Address:

 

 

 

 

 

DRIVER INFORMATION (Please complete for each driver you want to insure)

Driver 1

 

Driver 2

 

 

 

 

 

Name:

 

Name:

 

 

 

Marital Status:

Marital Status:

 

 

 

 

Gender:

Date of Birth:

Gender:

Date of Birth:

 

 

Date Licensed:

Date Licensed:

 

 

Driver’s License Number & State:

Driver’s License Number & State:

 

 

Social Security Number:

Social Security Number:

 

 

 

 

VEHICLE INFORMATION (Please complete for each vehicle you want to insure)

Driver 3

Name:

Marital Status:

Gender:

Date of Birth:

Date Licensed:

Driver’s License Number & State:

Social Security Number:

Vehicle 1

 

 

 

Vehicle 2

 

 

 

 

Vehicle 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle ID Number (VIN):

 

 

Vehicle ID Number (VIN):

 

 

 

Vehicle ID Number (VIN):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year/Make/Model:

 

 

Year/Make/Model:

 

 

 

Year/Make/Model:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Annual Mileage:

 

 

 

Annual Mileage:

 

 

 

Annual Mileage:

 

 

 

 

 

 

 

 

 

 

 

 

 

Usage:

 

‰ Business

‰Pleasure

Usage:

‰ Business

‰Pleasure

Usage:

‰ Business

‰Pleasure

 

‰ Carpool

 

‰ Other

‰ Carpool

 

‰ Other

‰ Carpool

 

‰ Other

 

 

 

 

 

 

 

Anti-lock

 

‰None

‰4 Wheel Standard

Anti-lock

‰None

‰4 Wheel Standard

Anti-lock

‰None

‰4 Wheel Standard

Brakes:

 

‰4 Wheel

‰After market

Brakes:

‰4 Wheel

‰After market

Brakes:

‰4 Wheel

‰After market

 

 

 

 

Air Bag:

 

‰None

‰ Driver

Air Bag:

‰None

‰ Driver

Air Bag:

‰None

‰ Driver

 

 

‰ Driver & Passenger

 

‰ Driver & Passenger

 

‰ Driver & Passenger

 

 

‰ None

‰ Alarm Only

 

‰ None

 

‰ Alarm Only

 

‰ None

 

‰ Alarm Only

 

 

‰ Vehicle Retrieval System

 

‰ Vehicle Retrieval System

 

‰ Vehicle Retrieval System

Anti-theft:

 

‰ VIN Etching

 

Anti-theft:

‰ VIN Etching

Anti-theft:

‰ VIN Etching

 

 

‰ Active Disabling Device

 

‰ Active Disabling Device

 

‰ Active Disabling Device

 

 

‰ Passive Disabling Device

 

‰ Passive Disabling Device

 

‰ Passive Disabling Device

Percentage of Use per Driver: Driver 1 _______

Percentage of Use per Driver: Driver 1 _______

Percentage of Use per Driver: Driver 1 _______

Driver 2 _______ Driver 3 _______

 

Driver 2 _______ Driver 3 _______

Driver 2 _______ Driver 3 _______

 

 

 

 

Vehicle Garaged Mailing Address: ‰ Yes‰ No

Vehicle Garaged Mailing Address: ‰ Yes‰ No

 

Vehicle Garaged Mailing Address: ‰ Yes‰ No

CURRENT INSURANCE INFORMATION

 

 

 

Carrier:

Years with Carrier:

 

 

Bodily Injury Limits:

Property Damage Limit:

 

 

Collision Deductible:

Comprehensive Deductible:

 

 

DRIVING HISTORY Please list ALL accidents and violations for ALL drivers in the last 36 months (At-Fault, Not-at-Fault, Moving Violations, etc.)

Driver:

Date:

Type:

 

 

 

Driver:

Date:

Type:

 

 

 

Driver:

Date:

Type:

 

 

 

INFORMATION RELEASE FORM

As part of the application process in obtaining the insurance coverage you are requesting from licensed insurance carriers of Allen Financial Insurance Group, Inc. and/or it’s licensed carriers may order one or more consumer reports. A consumer report may contain information on credit history, medical conditions, driving records, criminal activity and hazardous sports, among other things.

Under the Fair Credit Reporting Act, Allen Financial Insurance Group, Inc. and/or it’s licensed carriers may review consumer reports to evaluate anyone who applies for this insurance. In the event that coverage is denied to you based wholly or partly on information in a consumer report you will be notified of this fact and given the name and address of the consumer reporting agency making the report.

It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or to the Company until accepted by the Company or Companies but that the information contained herein shall be the basis of the contract should a policy be issued.

WARRANTY

I/We understand and agree that any misstatement of warranty or fact on this application shall be considered a violation of coverage afforded under any policy issued on the basis of this application. I/We understand and agree that this application shall form part of any policy issued.

APPLICANT

 

 

 

 

 

 

Signature

 

 

 

Date

 

 

BROKER

 

 

TELEPHONE (

)

 

 

 

 

 

 

 

 

 

Form Characteristics

Fact Name Fact Description
Insured Information The application requires personal details of the insured, including full names, address, and contact information.
Driver Information Details for each driver to be insured must be provided, including dates of birth, marital status, and driver's license information.
Vehicle Information Information about each vehicle, including the Vehicle Identification Number (VIN), year, make, model, and usage, is essential to complete the application.
Usage Types Applicants must specify how often each vehicle will be used, which can include options like business, pleasure, carpool, or other purposes.
Insurance History The application requests current insurance carrier details, including the length of time with the carrier and coverage limits.
Driving History All accidents and driving violations for the past 36 months must be disclosed for any driver listed in the application.
Warranty Clause The application includes a warranty, stating that any false information may void the insurance policy once issued.
Information Release Applicants consent to consumer reports being ordered, which may include credit history and driving records, as part of the application process.
Binding Agreement The application is not binding until formally accepted by the insurance company, although the information provided will serve as the basis for the policy.
State-Specific Regulations Each state may have specific laws that govern the automobile insurance application process and required information, affecting the form used.

Guidelines on Utilizing Automobile Insurance Application

Completing the Automobile Insurance Application form is a vital step in securing coverage for your vehicle. The following instructions will guide you through the process, ensuring that all critical information is provided accurately. This promotes a smooth application experience and helps avoid any delays in coverage.

  1. Begin by entering your Insured Information. Provide your full name, address, city, county, state, zip code, phone numbers, and email address. Make sure to indicate if you rent or own your home.
  2. Next, proceed to the Driver Information section. Fill out details for each driver you wish to insure. Include name, marital status, gender, date of birth, date licensed, driver's license number and state, and social security number for each driver listed.
  3. Then, move on to the Vehicle Information. Complete this section for each vehicle you want to insure. Record the vehicle ID number (VIN), year, make, model, annual mileage, and purpose of use (such as business or pleasure). Indicate any special features like anti-lock brakes and air bags.
  4. For each vehicle, specify the percentage of use per driver. Clearly detail how much each driver operates each vehicle.
  5. Provide the Current Insurance Information, filling out your current insurance carrier, how long you have been with them, and your coverage limits, including bodily injury limits, property damage limit, and deductibles for collision and comprehensive coverage.
  6. Document your Driving History by listing all accidents and violations for all drivers over the last 36 months. Include the name of the driver, date of incident, and type of incident.
  7. Read and sign the Information Release Form, acknowledging that consumer reports related to your application may be reviewed to assess your insurance coverage eligibility.
  8. Finally, provide your signature and date at the bottom of the application, confirming that all information provided is accurate and true.

Once the form is complete, fax it along with the relevant pages of your current insurance policy to Allen Financial Insurance Group, as outlined in the instructions. Ensure that all sections are filled out accurately to expedite the review and approval process.

What You Should Know About This Form

What information do I need to provide on the application?

You will need to provide personal details such as your name, address, and contact information. For each driver you want to insure, you'll list their information, including marital status, gender, and driving history. You'll also need vehicle details, like the Vehicle ID Number (VIN), make, model, usage type, and safety features. If you have current insurance, include your carrier information as well.

How many drivers can I include in the application?

You can include up to three drivers on the application. For each one, you must provide their basic information, including their driving history and vehicle percentage of use. Make sure to fill out the information accurately for every driver to ensure proper coverage.

What if I have had accidents or violations?

You are required to disclose all accidents and violations for every driver listed in the last 36 months. This includes both at-fault and not-at-fault accidents as well as any moving violations. Full disclosure will help the insurance company assess your risk accurately.

Will I be notified if my insurance coverage is denied?

If your coverage is denied based on information obtained from a consumer report, you will receive notification. The notification will include the name and address of the reporting agency that provided the information. This process is required under the Fair Credit Reporting Act.

What happens after I submit the application?

Submitting the application does not guarantee coverage. The application must be accepted by the insurance company before a policy can be issued. However, the information you provided will serve as the basis for the insurance contract if a policy is approved.

Do I have to provide my Social Security Number?

Yes, you need to include the Social Security Number for each driver being insured. This information will be used for identification and to facilitate background checks during the application process.

Common mistakes

Filling out the Automobile Insurance Application form can be straightforward, but it’s easy to make mistakes that may cause delays or complications. One common mistake is failing to provide complete driver information. Each driver’s details, including name, date of birth, and driver’s license number, must be included. Missing even one piece of information makes it challenging for the insurance company to process the application.

Another frequent error is not updating the address and contact information. Life changes, such as moving to a new home or changing phone numbers, should be reflected on the application. Providing outdated information can result in communication issues or even affect the policy coverage.

People often overlook listing all vehicles that need to be insured. It’s crucial to include the Vehicle ID Number (VIN), year, make, model, and usage type for each vehicle. Omitting a vehicle can lead to coverage gaps, which can have serious consequences if an accident involves that vehicle.

Inaccuracies in the driving history are also common. Applicants sometimes forget to include all accidents and violations, or they may not report them accurately. This can impact the quote and premium, leading to potential denial of coverage later on.

Additionally, individuals may neglect to specify the percentage of use per driver for each vehicle. This information helps insurers assess risk accurately. Not providing it can lead to a miscalculated premium, which might change after the policy is issued.

Another mistake is overlooking the need to verify current insurance information. Listing incorrect carrier details and coverage limits may create confusion, which could delay the underwriting process.

Failing to understand the implications of the information they provide is a significant error. Misstatements or omissions can be considered violations under warranty agreements, leading to a loss of coverage. When filling out the application, it’s essential to double-check all information for accuracy.

Lastly, neglecting to read the entire application thoroughly can lead to misunderstandings. Insurance applications often contain important information about how the insurance company will use the provided data. Ignoring this section can result in unexpected surprises down the line.

Documents used along the form

When applying for automobile insurance, it's common to complete the Automobile Insurance Application form. However, this is usually accompanied by several other important documents. Each document serves a specific purpose in the application process, ensuring that both the applicant and the insurance company have all the necessary information to establish coverage. Below is a list of commonly required forms and documents that may be needed along with your application.

  • Declarations Page: The declarations page from your current policy outlines your existing coverage limits, deductibles, and additional information relevant to your insurance history. It is essential for the new insurer to understand your prior coverage.
  • Information Release Form: This form allows the insurance company to obtain various background information, including credit history and driving records, to assess your application. Your consent is needed to process your request accurately.
  • Driving History Report: This report details any accidents or violations you have had in the last few years. Providing an accurate account helps the insurer evaluate potential risks and determine your premium.
  • Proof of Identity: A government-issued identification, like a driver’s license or ID card, is often required to verify your identity and ensure that the information on your application is accurate.
  • Payment Information: In many cases, you will need to provide payment details for the initial premium. This can include banking information or a credit card number to process the payment.
  • Prior Insurance Verification: This document confirms your previous insurance coverage. It helps the insurer understand your insurance history and may impact your eligibility or premium rate.
  • Vehicle Registration: A copy of your vehicle registration serves to verify ownership of the vehicle you wish to insure. It ensures that the insurance policy is issued to the correct owner.

Providing all these documents along with your Automobile Insurance Application form will streamline the insurance process and help achieve a more accurate assessment of your coverage needs. If you have questions about any of these documents, don't hesitate to reach out for clarification. Being informed will help you secure the best possible insurance options for your situation.

Similar forms

  • Homeowner's Insurance Application: Similar to the Automobile Insurance Application, this form collects personal and property information. It includes details like the applicant’s name, address, and information about the property being insured.

  • Renters Insurance Application: This document shares a similar structure, as it requires personal identification and details about the belongings being insured. Both applications ask for the insured's address and contact information.

  • Health Insurance Application: Like the automobile application, this form gathers personal information, including contact details and medical history. Both involve questions that assess risk for coverage and often require a declaration of existing conditions.

  • Life Insurance Application: This application is similar in that it collects personal and health-related information. It asks for details like the applicant's name, date of birth, and health history, akin to the data collected in the automobile application.

Dos and Don'ts

Filling out an Automobile Insurance Application can be straightforward if you keep a few important guidelines in mind. Below is a list of things you should and shouldn't do during this process.

  • Do ensure accurate information: Double-check all details, including names, addresses, and identification numbers. Accuracy is crucial.
  • Do include all drivers: List every individual who will drive the insured vehicle. This helps avoid potential coverage issues later.
  • Do disclose your driving history: Include all accidents and violations within the last 36 months, whether at-fault or not. Honesty is the best policy.
  • Do read the entire application: Understanding the questions and requirements can prevent mistakes and misunderstandings.
  • Do submit additional documents: If you have a current insurance policy, include the declarations page as requested.
  • Don't rush through the application: Take your time to ensure that each section is filled out completely and accurately.
  • Don't omit essential information: Missing details can lead to complications in securing coverage or filing claims.
  • Don't forget to sign and date: An unsigned application can delay the processing of your policy.
  • Don't provide false information: Misrepresentations can lead to the denial of coverage or claims in the future.
  • Don't hesitate to ask for help: If something is unclear, reach out to the insurance provider for clarification before submitting.

Misconceptions

Understanding the automobile insurance application form is crucial for prospective policyholders. Unfortunately, several misconceptions can lead to confusion. Here are eight common misconceptions, along with explanations to clarify the facts.

  • It's just a formality. Many believe completing the application is a mere formality. In reality, it is a critical step that significantly impacts coverage and premiums.
  • Only my driving history matters. Some think only their driving record influences their application. While driving history is important, factors like vehicle information and personal details also play a significant role.
  • My coverage is guaranteed if I fill out the form. Many assume that submitting an application guarantees insurance coverage. Coverage is not guaranteed until the insurer accepts the application and issues a policy.
  • All my previous insurance history is irrelevant. Applicants often believe their past insurance coverage is unimportant. Insurers use this information to assess risk and determine premiums.
  • Incorrect information can be fixed later. Some think they can provide any information and correct mistakes later. Misstatements may lead to denial of claims or cancellation of the policy.
  • I don’t need to disclose all drivers. Applicants might think excluding certain drivers will not matter. However, all potential drivers must be listed to ensure proper coverage.
  • Only serious violations are significant. There is a belief that only major incidents, like DUIs, affect the application. Minor violations can also impact premiums and approval prospects.
  • It’s okay to skip the consumer report section. Some applicants choose to ignore the consumer report disclosures. Skipping this section can result in a lack of transparency and possible policy issues later on.

Awareness of these misconceptions is essential for ensuring a smooth application process. Applicants should approach the application with thoroughness and honesty to avoid complications down the road.

Key takeaways

When filling out and using the Automobile Insurance Application form, it’s essential to understand a few key aspects. Here are some important takeaways to keep in mind:

  • Complete Information: Make sure to provide accurate and complete details for all sections, including personal information, driver details, and vehicle specifics. Missing or incorrect information can delay the application process or lead to issues with coverage.
  • Driving History Matters: Be honest about your driving history. You must list all accidents, violations, and claims from the past 36 months. This information helps insurance companies assess risk and determine your rates.
  • Consumer Reports: Understand that the insurance company may order consumer reports as part of your application. They may review your credit history, driving records, and other relevant information to evaluate your eligibility for coverage.
  • Warranties and Agreements: Familiarize yourself with the warranty section. Any misstatements or omissions can impact your insurance coverage. It’s essential to agree to the terms to ensure that your application is valid.

Overall, taking the time to fill out the Automobile Insurance Application accurately will help you secure the right coverage for your needs.