Application

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Please complete the below application in its entirety.

Application
Your Full Name:
Resident Street Address:
City:
State:     Zip:
   
Mailing Address:
City:
State:     Zip:
   
Phone:  
Contact E-mail Address:
 

Are you currently insured with Camico Mutual Insurance or through CAMICO Insurance Services?
Yes No

   

Are you a member of a State CPA Society?
Yes No

   
If so, which one?
 
Number of Youthful drivers in your Household:

(Defined as individuals under age 21 living in your house and holding a valid Driver's License.)

 
When would you like coverage to start?:

For your convenience, there are 12 monthly enrollment periods – starting on November 1st.

To enroll in a given month, you MUST apply and request coverage before 12 midnight the night before the monthly enrollment date.  Thus, to enroll in the May 1st period -  you must apply and request coverage by midnight on April 30th.
 

Has any Member of your household had a major driving violation (i.e., DUI, Reckless Driving, etc.) or a license suspension in the past 3 years?  
Yes No  

 

Select Liability Limit & Pricing:

 

* Please check to confirm that you currently have (and will maintain) the Required Underlying Insurance.
   

* By checking the box to the left, you verify that all of your representations on this application are true and accurate to the best of your knowledge.

   
* Please check the box to the left to confirm that you have been advised by the originating insurance producer and you understand that THE INSURANCE POLICY THAT YOU ARE APPLYING TO PURCHASE IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED "NONADMITTED" OR "SURPLUS LINE" INSURERS.   2.  THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS.  3.  THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED.  4.  CALIFORNIA MAINTAINS A LIST OF ELIGIBLE SURPLUS LINE INSURERS APPROVED BY THE INSURANCE COMMISSIONER. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE.

Please click the "Submit Application" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.