Insurance and Bonds Application

INSURANCE AND BONDS APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Partnership Corporation LLC Other

Policy and Bond Details

General Liability Commercial Auto Property Professional Liability / E&O Workers' Compensation Surety Bond

Policy Period To:

Bond Specifics (Complete if Surety Requested)

Coverage Options & Limits

Property Damage Bodily Injury Personal Injury (Libel, Slander) Professional Errors & Omissions Employment Practices Liability

Exclusions / Special Conditions

Claims / Loss History (Last 5 Years)

Prior claims or losses in past 5 years? Yes No

Police report Photos Repair/Estimate Other

Underwriting Questions

Has any policy been cancelled or non-renewed in the past 5 years? Yes No

Any bankruptcy filings by the applicant or principals in the last 7 years? Yes No

Any criminal convictions of applicant or key principals related to business operations? Yes No

Do operations involve hazardous activities (e.g., demolition, heavy blasting, scaffolding, deep excavation)? Yes No

Beneficiary / Payee Designation

Authorization, Declarations & Certifications

The undersigned applicant certifies that the statements and particulars contained in this application are true, complete and correctly recorded to the best of the applicant's knowledge. The applicant understands that this application, including any attachments and materials submitted in support hereof, will form the basis of any policy issued and that any material misrepresentation, omission, or misstatement may be grounds for denial of coverage or rescission of the policy.

The applicant authorizes any insurer, surety, financial institution, or claimant to release relevant loss, claim, financial or underwriting information to the company, its agents, and reinsurers for the purpose of underwriting, claims handling and audit. The applicant understands that premium is due as agreed and that failure to pay may result in termination or refusal to bind coverage. The applicant agrees to provide requested documents, cooperate with investigations, and permit physical inspections or audits where applicable.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim, statement, or application for insurance may be guilty of a criminal offense and subject to civil penalties. Where required by law, the applicant will be provided with a written notice of fraud warnings applicable to the applicant's jurisdiction.

Applicant acknowledges that issuance of a bond or policy may be conditioned upon review of additional underwriting information and that any interim binder or quote does not guarantee final acceptance. The applicant further acknowledges that the execution of this application does not bind the insurer or surety to issue the policy or bond, and does not bind the applicant to accept terms offered.

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