Insurance AESAcord Form

Insurance AESAcord Form

Applicant / Insured Information

Applicant Name:

Policy Details

Policy Period From:    To:

Coverage Options (Select all applicable)

General Liability — Bodily injury and property damage coverage
Property — Buildings, contents and business personal property
Automobile — Liability and physical damage for owned and hired vehicles
Workers' Compensation — Statutory benefits for employees
Professional Liability / Errors & Omissions
Umbrella / Excess Liability

Exclusions and Limitations

The following standard exclusions apply unless an endorsement is attached. Applicant acknowledges that coverage does not apply to losses arising from intentional acts, criminal conduct, pollution unless otherwise endorsed, war risks, nuclear hazard, and losses specifically excluded by endorsement. Applicant affirms they have reviewed policy exclusions and request special endorsements if necessary.

Beneficiary Designation

Beneficiary Name:

Claims / Loss History

Has the applicant had any claims, losses or incidents in the past five years? Yes No

Loss / Claim Notice (If reporting a current claim)

Date of Loss:

Estimated Amount of Damage: $

Documentation Checklist

Please attach or indicate documents submitted with this form: Police report Photographs of damage Repair estimates Receipts or proof of value Other supporting documents

Declarations and Authorization

I certify that the information provided in this form is true and complete to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage or rescission of the policy. I authorize the insurer and its representatives to obtain such information as may be necessary to underwrite and service the policy, including loss history and claims information. I acknowledge that submission of this form does not in itself bind coverage; coverage, if any, is subject to the terms, conditions and endorsements of the issued policy.

Notice Regarding Fraud: Any person who knowingly submits false information or conceals information for the purpose of obtaining insurance benefits may be subject to civil or criminal penalties as provided by law.

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