Insurance Annual Paperwork

INSURANCE ANNUAL PAPERWORK

Insured / Applicant Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Type (select all that apply): Auto Homeowners Life General Liability

Policy Period From:    To:

Coverage Selection and Limits

Select specific coverages and indicate limit where required:

Include comprehensive coverage    Limit:

Include collision coverage    Limit:

Bodily Injury/Property Damage    Per Occurrence Limit:

Include UM/UIM    Limit:

Exclusions & Notice

The policy does not provide coverage for losses arising from: intentional acts; fraudulent misrepresentation; wear and tear, deterioration, or mechanical breakdown not caused by a covered peril; losses resulting from criminal activity by the insured; war, nuclear hazard, or government seizure; loss resulting from operation of a motor vehicle by an excluded driver. This list is illustrative and not exhaustive. The full policy contract contains additional exclusions and conditions that govern coverage and claims handling.

Acknowledgment of Exclusions: I have read and understand the exclusions and agree that failure to disclose relevant facts may affect coverage.

Beneficiary Designation

Primary Beneficiary Name:    Relationship:    Share %:

Contingent Beneficiary Name:    Relationship:    Share %:

Claims History (Last 12 Months)

Have you had any claims, losses, or notices of potential claims in the last 12 months? Yes No

Policy Changes Requested

Authorization, Certification and Notices

I certify that the information provided in this annual update is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation, omission or failure to report changes in risk may result in denial of coverage, cancellation or rescission of the policy. I authorize the Company and its authorized representatives to obtain and verify information relevant to insurability, including claims history and other underwriting information, and to disclose information to affiliates and reinsurers as necessary to administer the policy.

I acknowledge my continuing duty to provide prompt written notice to the Company of any material change in risk or ownership, including but not limited to changes in occupancy, use, operation, or persons regularly operating insured property or vehicles. I understand that premiums and coverage are subject to change based on updated underwriting information.

Consent to Electronic Records and Signature: By signing below, I agree that this form, including my electronic signature, is legally binding and may be used in lieu of a paper signature where permitted. I retain the right to request a paper copy of this record.

Certification: I certify the foregoing statements and responses are true and accurate and acknowledge that false statements may be a criminal offense and may render coverage void as permitted by law.

Payment & Billing (if applicable)

Payment Method: Automatic debit Check Card

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