Insurance Annual Document Packet

INSURANCE ANNUAL DOCUMENT PACKET

Applicant / Insured Information

Insured Name:

Policy Details and Coverage

Policy Type: Auto Homeowners Liability Life Other:

Selected Coverages (check all that apply)

Collision
Comprehensive
Bodily Injury & Property Damage Liability
Uninsured/Underinsured Motorist
Personal Injury Protection
Medical Payments
Renters Contents

Exclusions and Acknowledgement

The following are typical policy exclusions which remain applicable unless expressly endorsed: intentional acts, fraudulent acts, wear and tear, nuclear hazard, war and civil unrest, criminal conduct, and loss due to use other than described in the policy. The insured acknowledges receipt and review of the exclusions listed above and understands that additional exclusions may apply as set forth in the policy language.

Insured Initials (acknowledging exclusions and receipt of notice):

Beneficiary Designation (if applicable)

Primary Beneficiary 1

Primary Beneficiary 2 (optional)

Claims History (past 12 months)

Have you had any claims or losses in the past 12 months? Yes No

If yes, provide details below for each loss. Provide police report numbers and attach documentation as indicated in the checklist.

Documentation Checklist

Please check documents being submitted with this packet: Police report Photos of damage Repair estimates Medical records/bills Other (describe):

Policy Changes / Updates

Has any information changed since the last policy period? Yes No

Declaration, Authorization and Certification

I certify that the information provided in this annual packet is true, complete, and accurate to the best of my knowledge. I understand that material misrepresentation, omission, or concealment of facts may result in denial of coverage or rescission of the policy. I authorize the insurer and its authorized representatives to obtain and verify any records, including claims history, motor vehicle records, credit-related information where permitted by law, and other underwriting information necessary to evaluate insurability or process claims.

I acknowledge that premium and policy terms may be adjusted based on the information provided. I agree to promptly notify the insurer of any material change in risk during the policy period. I further acknowledge that fraudulent statements or omissions may subject me to civil and criminal penalties under applicable law.

By signing below, I acknowledge that I have read, understand and accept the terms of this document and that this submission constitutes a request to update or renew coverage under the policy identified above.

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