See this page for definitions and question details.

Please fully complete and print the Application, obtain the insured's signature and forward it to your Program Administrator for processing Questions 10-15 print the response clearly on the line provided. if the question is unanswered or the response is greater than the maximum number indicated, the risk is not eligible. PUP special charge(s) apply if any answer to question 11 through 15 is greater than 0 (or greater than 640 for question 12)

Question 26: carefully read Question 26 and respond by checking "yes" or "no". if left unanswered or checked "no," the risk is not eligible.

If you are unsure what underlying coverage limits you are carrying, or are required to carry, we suggest contacting your local brokering agent.

QUESTION 27 Carefully read question 27 and respond by selecting one limit (A,B, or C) in the box provided. you MUST agree to maintain one of the three limits outlined in question 27, regardless of whether you currently own, lease, rent or operate a vehicle. if left unanswered, the risk is not eligible.

Limits B and C are available options ONLY if all drivers in the household are age 22 and over. Limit C is NOT available if there are any drivers age 70 or over in the household; and/or if any response makes the risk standard II (N/A in HI); and/or if any response makes the risk PUP Special.

If you are unsure what underlying coverage limits you are carrying, or are requred to carry we suggest contacting your local brokering agent.

QUESTION 28: complete the following for all members of your household age 14 and older. Also include on this list any other person who operates a vehicle owned, leased, rented or regularly operated by you or a member of your household at least 50% or more of that vehicle's use.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: I understand that as a part of the underwriting procedure, a consumer report may be prepared. Such reports may include information regarding my driving record, credit history, general reputation, personal characteristics and mode of living. I herby consent to the preparation of such reports and the disclosure of such reports to RLI Insurance Company and the producer of record. I understand that these reports will be handled in the strictest confidence, and that information as to the nature and the scope of these reports will be provided to me upon request.

FRAUD WARNING: any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties.

APPLICANT STATEMENT: The information given on this application is true and complete to the best of my Knowledge. I understand that any omission or misstatement of fact in the information given voids the policy. I agree that I will acquire and maintain Minimum Required Limits of Liability for all additional exposures (drivers, houses, vehicles, watercraft, etc.) if they become applicable during the policy period. The insured's Brokering Agent shall not have the right to make, alter, modify, or discharge any contract or policy issued on the basis of this Application. I understand that the application and prepayment of premium must be accepted by RLI Insurance Company.