UNIVERSAL INSURANCE AUTHORIZATION, DISCLOSURE & BROKER AGREEMENT
(For Use by Full Coverage LLC & Participating Insurance Carriers)
IMPORTANT: This Authorization allows Full Coverage LLC to collect information, pre-populate carrier applications (including Northland Insurance Company), and submit insurance quote requests on your behalf.
1. Purpose of This Authorization
By signing below, the Applicant authorizes Full Coverage LLC, its licensed agents, and any appointed or non-appointed insurance carriers or underwriting partners (collectively, “Producers”), to:
Collect information necessary to obtain insurance quotes.
Pre-populate, complete, and submit any supplemental or carrier-specific applications—including but not limited to Northland Insurance Company—based on information provided by the Applicant.
Communicate directly with the Applicant regarding rating, underwriting, documentation, and binding requirements.
Verify all information necessary for underwriting, risk evaluation, and compliance with applicable law.
This Authorization applies to new business, mid-term changes, and renewals.
2. Consent to Obtain Motor Vehicle Reports, Background Checks & Investigative Consumer Reports
The Applicant authorizes Full Coverage LLC and participating carriers to obtain:
Motor Vehicle Records (MVRs)
Commercial driving history & DOT records
Criminal background screenings (where permitted by law)
Loss runs & prior claims history
Investigative consumer reports regarding character, general reputation, and mode of living (pursuant to the Fair Credit Reporting Act (FCRA))
Upon written request, the Applicant may receive a description of the nature and scope of any investigative report obtained.
3. Consent to Obtain Credit Reports & Credit-Based Insurance Scores
In connection with this application for commercial automobile or any other insurance coverage, the Applicant authorizes:
Full Coverage LLC
Northland Insurance Companies
Any other participating carriers
to obtain credit reports and/or credit-based insurance scores, including through third-party vendors.
Such information will be used solely for the purpose of underwriting or rating the insurance for which the Applicant applies.
Authorization remains valid for renewals and future policy transactions unless revoked in writing.
4. Consent to Communications (TCPA-Compliant)
By signing, the Applicant authorizes Full Coverage LLC and its agents to contact them via:
Phone calls (including prerecorded or automated calls)
SMS/text messages
Email
Voicemail drops
Electronic document delivery and e-signature requests
These communications may include quote requests, underwriting questions, renewal reminders, or other insurance-related matters.
Msg & data rates may apply. Consent is not a condition of obtaining insurance.
The Applicant may opt out at any time by written request.
5. Use of Application Information
Information provided in this form may be used to:
Pre-populate Northland applications
Complete any required supplemental applications
Submit quote requests to multiple carriers
Determine eligibility, risk level, and rating
Comply with state and federal underwriting requirements
This Authorization does not bind coverage and does not amend any policy.
6. Applicant Acknowledgements
By signing, the Applicant agrees:
All drivers and vehicles used for business or commercial purposes have been disclosed.
The Applicant will immediately notify Full Coverage LLC of:
New drivers
New vehicles
Garaging location changes
Ownership changes
Accidents, claims, or losses (regardless of fault)
The Applicant acknowledges familiarity and compliance with current DOT Safety Regulations applicable to their operation.
Completion of this document is for quoting purposes only. Binding coverage requires completion of carrier-specific, state-required, and Northland-required supplemental applications.
Availability of coverage depends on underwriting qualifications and state law.
7. Fraud Statements (Required by Law)
ARKANSAS, MARYLAND, NEW MEXICO and OREGON: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
MAINE, TENNESSEE and WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits.
NEW JERSEY: Any person who includes false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive any insurer makes any claim or submits information containing any false, incomplete, or misleading information is guilty of a felony.
ALL OTHER STATES: Any person who knowingly, and with intent to defraud any insurance company or another person, files an application for insurance or statement of claim containing any materially false information, or conceals information for the purpose of misleading, commits a fraudulent insurance act, which is a crime.
8. State-Specific Underwriting Notices
Iowa, Illinois, New Mexico, Oregon, Washington, Wisconsin:
Signing this application does not bind the company to offer insurance nor obligate the applicant to purchase it. The application and supporting documents form the basis of any policy issued.
Montana: A single loss is among the insurance company’s criteria for nonrenewal.
South Carolina: The insurer may cancel this policy without cause during the first 90 days; after that, cancellation is limited to reasons stated in the policy.
9. Producer Compensation Disclosure (Northland Required)
For information on how Northland compensates its agents, brokers, or program managers, please visit:
https://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html
10. Certification & Signature
By signing below, the Applicant:
Confirms all information provided is true, accurate, and complete.
Authorizes Full Coverage LLC to submit this information to multiple insurance carriers.
Approves Full Coverage LLC to complete carrier applications on their behalf using information provided.
Acknowledges all disclosures in this Authorization.
Understands coverage is not bound until confirmed in writing by the carrier.
11. Disclaimer
This form is designed based on industry-standard insurance compliance practices. It is provided for general informational purposes only and is not legal advice. Consult a licensed attorney in your state for legal verification before relying on this document.