Business GL Bind Request

Business GL Bind Request

WHEREAS

WHEREAS Applicant Name: (the "Applicant") requests the procurement and binding of Commercial General Liability insurance for its business operations described herein; and

WHEREAS Broker/Producer Name: is authorized by the Applicant to submit this bind request to Insurer: and to take binding action consistent with the terms herein; and

WHEREAS coverage is requested to become effective on Effective Date: subject to issuance of formal policy documents and payment of premium in accordance with the Payment Terms below.

Applicant Information

Corporation LLC Partnership Other:

Scope of Work / Operations

Provide a complete description of operations, activities, and any subcontracted work to be insured. Include any habitual jobsite conditions, use of heavy equipment, and routes for operations.

Policy Details Requested

Additional Insureds requested (list full legal names and relationship to Applicant):

Waiver of Subrogation requested:    Separation of Insureds (Cross-Liability):

Locations / Job Sites

Primary location and any additional sites where insured operations will occur. Include address, description of operations at each location, and any exposures of which the Insurer should be aware.

Payment Terms

Total Premium Due: . Payment schedule:

One-time payment upon binding Installment plan:

Late fee for overdue payments (if applicable):

Term and Termination

Coverage Term Start Date: ; Term End Date: .

Either party may terminate the request or any binder issued hereunder by providing written notice to the other party not less than days prior to the intended termination; provided that cancellation of binding by the Insurer may also occur in accordance with the terms and conditions of the policy and applicable law.

Confidentiality

All non-public business information submitted in connection with this request shall be treated as confidential by Broker and Insurer to the extent permitted by law. Notwithstanding the foregoing, Applicant acknowledges that necessary disclosures may be made to reinsurers, regulatory authorities, claims administrators or as otherwise required by law.

Authorization to Bind and Representations

Applicant represents and warrants that all information provided in this request is true, correct, and complete to the best of Applicant's knowledge. Applicant authorizes Broker/Producer to bind temporary coverage on behalf of the Insurer, subject to Insurer acceptance, payment of required premium, and issuance of formal policy documents. Any binding action taken by Broker/Producer must be expressly authorized in writing by the Insurer and shall be limited to the coverage, limits, and endorsements specified by Insurer at time of binding.

Attachments and Required Documentation

The following documents must accompany this request: current certificate(s) of insurance (if any), signed contracts requiring additional insured status, safety programs, loss runs for the prior five years, and any site-specific hazard documentation.

Attachments included with this request: Loss Runs Contracts Safety Programs Other:

Governing Law

This Bind Request and any binder or policy issued in connection herewith shall be governed by and construed in accordance with the laws of the state where the principal business location of Applicant is situated. Venue for any dispute arising under this request shall lie in the courts of that jurisdiction.

Entire Agreement

This document, together with any attachments referenced herein and any binder issued pursuant to it, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior or contemporaneous negotiations, agreements, representations, or understandings, whether written or oral.

Certifications and Acknowledgement

By signing below, Applicant certifies that Applicant is authorized to request coverage on behalf of the insured entity and that the information provided in this request is accurate and complete. Applicant understands that any binder issued may be subject to audit, modification, or cancellation in accordance with the terms of the final policy documents.

Broker/Producer Instructions

Broker must attach completed supplemental applications, verifies loss history, confirm underwriting acceptance in writing, and provide payment instructions. Broker attests that they have disclosed all material facts and known exposures to the Insurer prior to binding.

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