Insurance Application Agreement

INSURANCE APPLICATION AGREEMENT

Applicant Name:   Date of Birth:

APPLICANT / INSURED INFORMATION

Individual    Corporation    LLC    Other:

POLICY DETAILS

Property    Liability    Auto    Life    Other:

Policy Period: From to

COVERAGE SELECTIONS

Select coverages and specify limits where applicable:

Property Coverage — Limit:

Liability Coverage — Limit:

Personal Property — Sublimit:

Additional Coverages (specify):

CLAIMS / LOSS HISTORY

Have you had any losses or claims in the past five (5) years?   No    Yes

EXCLUSIONS & ACKNOWLEDGMENTS

The policy applied for will exclude losses arising directly or indirectly from acts or events such as intentional acts, war or military action, nuclear hazard, wear and tear, mechanical breakdown, and mold or pollution unless expressly endorsed. Applicant acknowledges receipt and review of standard exclusion language and understands that additional endorsements may be required for certain perils.

I acknowledge reading and understanding the exclusions described above:

BENEFICIARY / PAYEE DESIGNATION

DECLARATIONS, AUTHORIZATIONS, AND CERTIFICATIONS

The undersigned certifies that all statements in this application are true and complete to the best of their knowledge and that no material facts have been omitted. The undersigned understands that any material misstatement or omission may be grounds for denial of coverage, rescission of a policy, or adjustment of coverage and premiums retroactive to the effective date.

The undersigned authorizes the insurer and its representatives to obtain and verify information from any source, including but not limited to medical, employment, insurance, credit, and claims records, as necessary to underwrite the application and to process future claims. The undersigned further authorizes institutions and persons to release such information.

It is agreed that premiums due will be paid according to the insurer's billing terms. The insurer may cancel or nonrenew coverage as permitted by policy terms and applicable law; any return premium will be computed in accordance with the policy and insurer rules. By signing below, the applicant acknowledges receipt of this application and agrees that it becomes part of any policy issued in reliance upon it.

Fraud Warning: Any person who knowingly presents false information or conceals a material fact in order to obtain insurance coverage or payment may be subject to civil or criminal penalties and may forfeit coverage. I acknowledge that I have read and understand this fraud warning.

I certify that the information given in this application is complete and truthful and that I have read and agree to the terms and conditions set forth in this Insurance Application Agreement.

Certification: I hereby certify, under penalty of perjury, that the foregoing statements and any attachments are true and correct.

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