Named Insured

Honoree 1

If the Honoree is the same as the Named Insured, please re-enter the information here.

Honoree 2

If a second honoree is listed on the policy, enter their information. Otherwise, enter “N/A.”

Policy & Claim

Important Acknowledgements and Fraud Warning

Insurance fraud is a serious crime. The circumstances leading to a cancellation must have been unknown and unforeseen at the time your policy was purchased. Fraud includes the purchase of a policy where a claim is discovered to arise from a prior known circumstance.

BY SIGNING BELOW, YOU ACKNOWLEDGE, AFFIRM, AND CONFIRM THE FOLLOWING:

Please Initial

DS
DS
DS
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We understand that navigating these rules can be complex. If you believe you may have purchased this policy in violation of the above stipulations (due to a prior known circumstance), you may contact us immediately to discuss a policy voidance and premium refund, as opposed to filing a potentially fraudulent claim.

WARNING

Do not continue unless you have an active policy and a covered loss.

 

Filing a fraudulent claim is a crime punishable by law. By clicking “NEXT” below, you confirm you’ve read and understand the Claims Fraud Warnings.*
https://brite.co/claims-and-fraud-warnings/