Business Umbrella Application

BUSINESS UMBRELLA APPLICATION AND AGREEMENT

RECITALS

WHEREAS, Applicant Business Name: (the "Applicant") operates the business described in this application and seeks to obtain umbrella liability coverage; and

WHEREAS, Insurer Name: (the "Insurer") underwrites excess and umbrella policies and requires this application and agreement as part of its underwriting and issuance process; and

WHEREAS, Applicant and Insurer agree to the terms contained in this Application and Agreement and to the representations, disclosures, and obligations set forth herein to permit Insurer to evaluate and, if approved, bind umbrella coverage.

APPLICANT INFORMATION

SCOPE OF WORK

Describe the nature of business operations, locations, and activities for which umbrella coverage is sought. Include limits of operations, subcontractor use, and any high-risk activities.

COVERAGE REQUESTED & UNDERLYING INSURANCE

CLAIMS HISTORY & RISK MANAGEMENT

Any claims, suits or losses in the past five (5) years? Yes No

PAYMENT TERMS

Premium Amount: $   Payment Schedule:

Payment Due Date (first installment):

Late Fee / Interest on Overdue Payments:

Applicant acknowledges that failure to pay premiums when due may result in cancellation or non-renewal of umbrella coverage, subject to Insurer's underwriting and applicable notice requirements.

TERM AND TERMINATION

Policy Period Commencement Date:   Expiration Date:

Either party may terminate any bound coverage in accordance with the terms and conditions of the issued policy. Termination for convenience by either party requires written notice provided at least days prior to the desired termination date, except as otherwise provided by policy or law.

CONFIDENTIALITY

All information disclosed in this Application, including underwriting materials, financial data, claims history and risk management documentation, shall be treated as confidential by Insurer and Applicant. Insurer may disclose such information as required by law, to reinsurers or as necessary for underwriting, claims handling, audit or legal defense. Applicant represents that disclosures made herein are accurate and may be relied upon by Insurer in underwriting and pricing.

REPRESENTATIONS, WARRANTIES AND AUTHORIZATION

Applicant represents and warrants that all statements, answers and representations in this Application are true and complete to the best of Applicant's knowledge. Applicant understands that any material misrepresentation, omission or concealment of fact may be grounds for denial of coverage or rescission of any issued policy. Applicant authorizes Insurer to obtain and verify any underwriting information, including but not limited to loss runs and prior policy terms, from brokers, prior carriers, and third-party data providers.

GOVERNING LAW

This Application and any policy issued in reliance hereon shall be governed by and construed in accordance with the laws of the state in which the principal insured location is situated, without regard to conflict of law principles.

ENTIRE AGREEMENT

This Application, together with any attachments, exhibits and any subsequently issued policy declarations, endorsements and schedules, constitutes the entire agreement between Applicant and Insurer concerning the subject matter hereof. No amendment or waiver shall be effective unless in writing and signed by an authorized representative of Insurer.

ADDITIONAL INFORMATION

By signing below, Applicant certifies that the information contained in this Application is true and complete, understands that Insurer will rely on these statements for underwriting and that coverage, if issued, is subject to the terms, conditions and exclusions of the policy.

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