Insured Name

First Last

(as it should appear on the policy)

Mailing Address:

Location of Risk:

Proposed Effective Date: From

Applicant is:

Individual

Corporation

Partnership

Joint Venture

Other

PREVIOUS INSURER AND PRIOR LOSS INFORMATION

Has the insured or applicant had 3 years of prior coverage?

Yes

No

Has the insured or applicant had any prior claims or losses in the last 3 years?

Yes

No

Prior Policy Date

_______ to ________

Carrier Name

Coverage Type: Liab/PHD/MTC

POLICY #

# of Units Insured

Any loses within the past 5 years?

If YES please upload on the related documents attaching box below.

Amount Paid

Driver Involved in Loss

Upload Your Current Insurance Policy or Related Documents

Drop files here or

Max. file size: 20 MB, Max. files: 10.

FLORIDA FRAUD STATEMENT:

Section 817.234 (1)(b) “Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.”

TENNESSEE / VIRGINIA FRAUD STATEMENT:

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Upon requesting quotes and/or placement for the coverage listed herein, the producing retail broker hereby confirms that he/she has performed any and all diligent searches, as may be required by statute, for coverage through licensed carriers or other means of placement. Where allowed by governing statutes, "diligent effort" may not require an actual physical search and declination on each risk, but may be based on the retail producing broker's own experience, opinion and overall knowledge of acceptability in the admitted marketplace.