Insurance Agency Disclosures

Insurance Agency Disclosures

Agency Name:   License Number:

Producer/Agent:   Producer License No.:

Applicant / Insured Information

Policy Details

Policy Period: From through

Coverage Selections

The following coverage classes were discussed. Please indicate which apply to the quoted/purchased policy:

Property Coverage

General Liability

Commercial Auto

Workers' Compensation

Umbrella/Excess Liability

Other (describe below)

Exclusions

Standard policy exclusions may include, but are not limited to, intentional acts, criminal acts, war, pollution (unless specifically endorsed), and losses excluded by endorsement. Applicant expressly acknowledges receipt of this general notice of exclusions and understands that the specific policy form and endorsements control actual coverage.

Agency Relationship & Compensation

The Agency discloses the following relationship(s) and compensation arrangements with respect to placement, procurement, and servicing of insurance:

Agency acts as agent of insurer(s) (authorized to bind coverage on behalf of insurer).

Agency acts as agent of the insured (duties include advocacy, placement and service on behalf of insured).

Agency acts in a broker capacity and will seek placement with one or more insurers.

Compensation disclosed to applicant:

Referral or contingent fees: Applicable    Not Applicable

Conflicts of Interest / Other Disclosures

The Agency will disclose known material conflicts of interest. The Agency may receive compensation, contingent commissions, or other remuneration from insurers or other third parties; such arrangements may create incentives to place coverage with particular markets. By signing below, the applicant acknowledges receipt of notice of possible compensation arrangements and the applicant's right to request more detailed compensation information in writing.

Privacy and Use of Information

The Agency collects personal and business information necessary for underwriting, claims handling, and policy administration. Information may be shared with insurers, reinsurers, service providers and regulatory authorities as required. Applicant consents to the collection, use and disclosure of such information for insurance-related purposes.

Applicant consents to information sharing: Yes    No

Beneficiary / Additional Interested Parties (if applicable)

Enter beneficiary or additional interested party information to be recorded on policy or endorsements where permitted.

Declaration and Certification

I certify that the information provided above is true, complete and correct to the best of my knowledge. I acknowledge that the Agency has disclosed its agency relationship(s), estimated compensation, and general exclusions. I understand that the final terms of coverage, limits, exclusions, and conditions are contained in the issued policy and any endorsements and that no agent or representative may alter or waive policy provisions except by written endorsement issued by the insurer.

By signing below I acknowledge receipt of these disclosures, consent to the uses of information described herein, and authorize the Agency to proceed with placement consistent with the relationship(s) disclosed above.

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