Insurance Agency Paperwork

INSURANCE AGENCY PAPERWORK

Applicant / Insured Information

Applicant Name:

Agency / Broker Information

Agency Name:

Policy Details

Coverage Selection (select all that apply)

Primary Coverages Property Coverage Liability Coverage Auto Coverage Umbrella / Excess Liability Professional Liability (Errors & Omissions)

Exclusions and Limitations

The policy issued pursuant to this application will contain standard exclusions including, but not limited to, intentional acts, known prior losses not disclosed, losses arising from war or nuclear hazard, and bodily injury or property damage excluded by endorsement. The insurer may impose additional endorsements or limitations as required by underwriting. Applicant must disclose any material facts that would influence acceptance, rating, or placement of coverage.

Beneficiary Designation

Designate one or more beneficiaries for applicable policy proceeds. Percentages must total 100% where applicable.

Claims History & Documentation

Underwriting and Risk Questions

1. Has any insurer cancelled or declined coverage for you in the past 5 years? Yes No

2. Do you operate a business or have rental property to be insured? Yes No

Authorization, Declaration and Certification

I hereby declare that all statements and answers in this application are true, complete, and correctly recorded to the best of my knowledge. I acknowledge that any material misrepresentation or omission may be the basis for denial of coverage, rescission of policy, or reduction of benefits. I authorize the insurer and its agents to obtain and exchange information pertinent to underwriting and claims, including but not limited to claim history, inspection reports, and other relevant underwriting data. I agree to furnish additional information and to execute any documents reasonably required by the insurer. I understand premiums are due in accordance with the policy and that failure to pay premiums when due may result in cancellation of coverage.

By signing below I certify under penalty of perjury that the information provided in this application is true and accurate and that I have authority to provide it. I acknowledge receipt of policy terms, conditions, limitations and the insurer's right to investigate the statements made herein.

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