Insurance All Risks Application

Insurance All Risks Application

1. Applicant / Insured Information

Applicant Name:

Individual Corporation Partnership Trust Other

Date of Birth (if individual):    Tax ID / SSN:

2. Policy Details

Policy Type:    Proposed Policy Number:

Coverage Limit (Sum Insured): $    Deductible: $    Annual Premium: $

Policy Period From:    To:

3. Schedule of Insured Property (Describe each item or location)

If additional scheduled items exist, attach a separate schedule using the same format and submit with this application.

4. Coverage Options (Check applicable)

Fire and Lightning Theft and Burglary (specify sublimit if required): $ Accidental Physical Loss or Damage Transit and Marine Inland Transit Flood (if requested, provide details and sublimit): $ Earthquake (if requested, provide details and sublimit): $ Business Interruption / Consequential Loss (specify indemnity period): Third Party Liability (specify limit): $

5. Exclusions (Standard — all policies issued will include detailed exclusion endorsements)

The Insurer shall not be liable for loss or damage directly or indirectly caused by or resulting from and arising in connection with the following, whether or not insured perils contribute concurrently or in any sequence to the loss:

1. Wear and tear, gradual deterioration, latent defect, inherent vice, corrosion, mildew, rust, rot or depletion; mechanical, electrical or electronic breakdown, failure, breakdown of machinery, boilers or pressure vessels unless specifically endorsed.

2. War, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, military or usurped power, confiscation, requisition, or nationalisation.

3. Nuclear reaction, nuclear radiation or radioactive contamination, or any consequence thereof.

4. Loss or damage caused by pollution or contamination unless such loss is caused by a sudden, identifiable, unintended and unexpected event which occurs at a specific time and place.

5. Dishonest or criminal acts of the Insured, or willful misconduct, or any loss resulting from fraudulent acts.

6. Biological hazards, pests, insects, vermin, fungus, or deterioration due to infestation.

6. Prior Insurance and Loss History

Has any applicant had insurance declined, cancelled or renewal refused in the past 5 years? Yes No

Claims or losses in the past 5 years:

7. Additional Interests / Beneficiary / Mortgagee

Is there a mortgagee, loss payee, or other party with an insurable interest to be noted on the policy? Yes No

8. Declarations, Authorizations and Warranties

The undersigned declaring to be the Applicant or an authorized officer of the Applicant, warrants and represents that the information contained in this application is true, complete and material to the Insurer's consideration of the risk. The Applicant acknowledges a duty to disclose all material facts known to the Applicant and that failure to disclose such facts may render any resulting policy voidable or give the Insurer grounds for denial of coverage.

The Applicant authorizes the Insurer and its representatives to make such investigations and inquiries as are necessary to verify the information supplied, including but not limited to inspection of premises, review of loss history and prior insurance records. The Applicant consents to the release of information to other insurers for purposes of underwriting and claims investigation.

The Applicant understands that coverage will be subject to the terms, conditions, limits, and exclusions contained in the policy and any endorsements issued. Payment of premium does not constitute acceptance of any application or bind coverage except as may be agreed in a written binder signed by an authorized representative of the Insurer.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim, or knowingly makes a false statement in an application for insurance is subject to civil and criminal penalties under applicable law.

9. Agent / Broker Information

10. Applicant Certification

By signing below the Applicant certifies under penalty of perjury that the information provided in this application is true and correct to the best of the Applicant's knowledge and belief, and that no material facts have been withheld. The Applicant agrees that this application, including any schedules or attachments, shall form the basis of any policy issued and may be relied upon by the Insurer.

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