Personal Firearms Insurance

Coverage for defending yourself and others from serious threat with a legally possessed firearm under either HR218 or state concealed carry permit.

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If you have ever been convicted of a felony we are unable to provide coverage for you under this policy

Applicant Info

Applicant Information

(Must match with business registration)

Primary Applicant Name ^*

Primary Phone Number ^*

Primary Email ^*

Employment Information

Current or Previous Employer ^*

Dates Employed ^*

Primary Physical Address

(Can not be P.O. Box or similar)

Street Address ^*

City ^*

State ^*

Zip Code ^*

Mailing Address

(If different from primary address)

Street Address

City

State

Zip Code

Coverage Information

Choose Coverage: ^*

Red ($125 Annual Premium)

White ($225 Annual Premium)

Blue ($350 Annual Premium)

Requested Effective Start Date of Coverage ^*

Authorization/Disclosures

Disclosure/Authorization/Declarations

WARNING NOTICE: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud.

The undersigned Applicant authorizes the Company, its agents, and representatives to secure claims information from my current and previous insurance carriers.

Acknowledgement, consent and waiver: Upon purchase coverage will be placed with Conifer Insurance company which is rated by A.M. Best Company as B+. The agent, employees, independent contractors, directors and officers make no representation as to the financial status of the insurance carrier. The undersigned requests and grants authority to place coverage as described above.

The undersigned declares that to the best of their knowledge and belief the statements set forth herein are true. The signing of this application does not bind the undersigned to purchase insurance, nor does review of the application bind the insurer to issue a policy. It is agreed, however, that this application shall be the basis of the contract should a policy be issued.

By providing my signature below I am also confirming that I have not been convicted of a felony.

Signature

Typed name constitutes signature for application/disclosure purposes

Date

11/21/2024