Insurance Acknowledgements Form

INSURANCE ACKNOWLEDGEMENTS FORM

Applicant / Insured Information

Client Name:

Policy Number (if assigned):    Primary Insured (if different):

Policy Details & Coverage Acknowledgements

Policy Type (select all that apply):

Auto Liability
Collision
Comprehensive
Homeowners / Property
General Liability
Professional Liability / E&O

Policy Period: From to

Coverage Specifics — Acknowledgement

I acknowledge that I have received and read the summary descriptions for the coverages selected above and understand the limits, deductibles and conditions that apply. I specifically acknowledge the following (check each box to confirm receipt and understanding):

Receipt of liability limits and understanding of insurer and insured obligations under liability coverage.
Receipt of collision/comprehensive terms, including loss settlement and salvage provisions.
Receipt of principal exclusions applicable to selected coverages.
Receipt of claims reporting procedures and required documentation list.

Exclusions & Limitations

I acknowledge that certain losses are excluded or limited under the policy(ies). Common exclusions include but are not limited to intentional acts, war or nuclear hazard, wear and tear, and losses arising from fraudulent acts by the insured. I understand that specific exclusions applicable to my coverage are set forth in the actual policy contract and endorsement language.

Beneficiary / Payee Information (if applicable)

Authorizations, Certifications, and Notices

Authorization to Obtain Information: I authorize the insurer, its agents, representatives and administrators to obtain, review and exchange with other insurers, consumer reporting agencies, medical providers, employers, or claimants, any information necessary to underwrite, rate, administer or investigate claims related to this policy, including medical and claims history.

Certification of Accuracy: I certify that the statements and answers provided on this form are true and complete to the best of my knowledge and belief. I understand that any material misrepresentation, omission or concealment may be cause for denial of coverage, rescission of the policy, or denial of a claim.

Acknowledgement of Receipt: I acknowledge receipt of the policy, declarations page, required disclosures and any endorsements listed on this form or otherwise issued with the policy. Acknowledgement does not amend the contract; the policy language and endorsements control coverage determinations.

Consent to Electronic Delivery: I consent to receive policy documents, notices, endorsements, and billing communications electronically where permitted by law and agree that electronic delivery meets any statutory or contractual notice requirements, unless I notify the insurer in writing requesting paper delivery.

Assignment of Benefits (if applicable): I understand that assignment of benefits to third parties requires insurer approval and that assignment does not relieve me of obligations under the policy.

Fraud Warning

Fraud Warning: Any person who knowingly presents false information or conceals material facts with intent to defraud or mislead an insurer may be guilty of insurance fraud. Penalties for insurance fraud may include civil and criminal sanctions and may result in fines or imprisonment.

Confirmations

By signing below I confirm that I have reviewed the information provided on this Insurance Acknowledgements Form and the attachments indicated; that I have had an opportunity to ask questions and receive answers regarding coverages, limits, endorsements and exclusions; and that I understand the insurer's and my obligations under the policy.

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