Insurance Agent Layer Form

INSURANCE AGENT LAYER FORM

Applicant / Insured Information

Full legal name:

Date of birth:    Phone:    Email:

Agent license number:    Agent phone:    Agent email:

Policy Layer Summary

Primary Layer (Layer 1)

Policy number:    Policy type:

Coverage limit: $    Attachment point / Retention: $    Deductible: $

Premium for this layer: $    Policy period (start):    (end):

Excess Layer 1 (Layer 2)

Policy number:    Coverage limit: $

Attachment point: $    Premium: $

Excess Layer 2 (Layer 3)

Policy number:    Coverage limit: $

Attachment point: $    Premium: $

Coverage Options (check all that apply)

Property    General Liability    Professional / E&O    Cyber

Auto    Workers' Compensation    Inland Marine    Crime / Fidelity

Exclusions

The following are standard exclusions commonly applied to the layers described above: nuclear hazard, war and terrorism (except as specifically endorsed), intentional acts or willful misconduct, liability assumed under contract except where noted, pollution unless specifically endorsed, professional services not listed, and any exclusionary endorsements issued by the carrier. Additional carrier-specific exclusions and endorsements may attach to each layer.

Additional exclusions or endorsements attached: Yes

Beneficiary / Payee Information (where applicable)

Beneficiary name:

Relationship to insured:    Allocation percentage: %

Claims & Loss History

Any losses or claims in the last five (5) years: Yes    No

Estimated aggregate outstanding/reserved for open matters: $

Documentation Checklist

Policy declarations page(s)    Endorsements

Loss runs / claims history    Evidence of premium payment    Certificate(s) of Insurance

Agent Certification and Authorization

By signing below, the applicant and agent certify that the information provided in this Insurance Agent Layer Form is true, accurate, and complete to the best of their knowledge. The applicant represents that they have disclosed all material facts and prior claims affecting underwriting of the described layers. The agent represents that they have the authority to submit the enclosed documentation and to bind the applicant for purposes of placement discussions and premium transactions. The parties acknowledge that carriers may rely upon the statements made herein for underwriting and issuance of coverage, and that any material misrepresentation may result in rescission or denial of coverage as permitted by governing law.

Applicant consents to the exchange of underwriting, claims, and premium information between insurers, reinsurers, and authorized representatives for the purpose of placement, administration, and claims handling. The applicant authorizes the agent to execute certificates or binders necessary to evidence coverage consistent with the layer summaries contained in this form, subject to carrier terms and issuance of formal policy documents.

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