Is notarization required for this form?

Notarization is not typically required for insurance application forms, but specific endorsements or state laws may mandate it. Remote online notarization (RON) rules vary by state; ESIGN/UETA do not override statutory notary requirements, so verify with the state notary authority.

Can parties sign electronically under ESIGN?

Yes in most cases. The ESIGN Act and UETA render electronic signatures legally enforceable if intent, consent, attribution, and record retention are present. Consumer-facing financial or health disclosures may require specific consent language under 15 U.S.C. §7001.

What supporting documents should be attached?

Include proof of identity, loss runs, prior-policy declarations, and any underwriting exhibits referenced in the exclusion clause. For healthcare-related exclusions, attach HIPAA authorizations or patient consents. Accurate attachments speed review and prevent underwriting delays.

Who is authorized to sign this form?

Authorized signers are the named applicant, an officer with signing authority for corporate applicants, or an authorized agent listed on company letterhead. Brokers or agents may countersign, but insured signature and printed name are required for legal attribution and ESIGN compliance.

How can the form be amended or revoked?

Amendments require written agreement signed by all parties, clearly marking changes and dates. To revoke, execute a written cancellation or replacement form and notify the insurer in accordance with policy terms and any applicable state notice requirements.

How long should signed forms be retained?

Keep signed Insurance Application and Exclusion Forms for the policy term plus a minimum of three years; retain longer when federal or state law requires it. For HIPAA-related records, follow 45 CFR §164.530(j) which requires six years.

Electronic Signature
Templates
Insurance
Insurance Application and Exclusion Form

Insurance Application and Exclusion Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE APPLICATION AND EXCLUSION FORM

Applicant / Insured Name:

INSURED INFORMATION

Mailing Address Primary Contact Phone Email Address

Date of Birth: Social Security or Tax ID:

Occupation / Business Description

POLICY DETAILS

Policy Type (select all that apply):

Property Liability Auto Professional Liability Cyber Liability

Requested Coverage Limit Requested Deductible

Estimated Annual Premium: Existing Policy Number (if applicable):

Policy Period From: To:

COVERAGE OPTIONS

Select coverages to be included in the policy. Limits and sub-limits will be stated in the policy schedule.

Property Damage Coverage Bodily Injury Liability Personal Property Coverage Business Interruption Medical Payments Uninsured/Underinsured Motorist Cyber Liability

EXCLUSIONS AND ACKNOWLEDGMENTS

The following exclusions are common to the requested coverage. Applicant must initial each exclusion that the applicant acknowledges and accepts as not insured under this application unless specifically endorsed by the insurer.

War, invasion, acts of foreign enemies, hostilities (whether declared or undeclared), civil war Nuclear reaction, radiation, or radioactive contamination Intentional acts, criminal acts, or willful misconduct by the insured Wear and tear, gradual deterioration, inherent vice or latent defect Mold, fungus, bacterial contamination unless otherwise endorsed Flood and surface water (unless separate flood coverage is purchased) Earthquake and earth movement (unless earthquake coverage is purchased) Acts of terrorism unless terrorism coverage is specifically purchased Professional services and errors or omissions arising from professional advice (unless professional liability is purchased)

Other Exclusions (describe in detail)

By checking the exclusions above and signing this application the Applicant acknowledges that exclusions listed are understood and that coverage will not be afforded for excluded perils unless an express written endorsement is issued by the insurer.

BENEFICIARY DESIGNATION

Beneficiary 1 Name: Relationship: Share %:

Beneficiary 2 Name: Relationship: Share %:

Beneficiary 3 Name: Relationship: Share %:

PRIOR INSURANCE AND LOSS HISTORY

Prior Insurer Name

Prior Policy Period From: To:

Have you had any claims or losses in the past five years?

Yes No

If yes, provide details of each loss (date, description, amount paid or reserved)

DECLARATIONS, AUTHORIZATIONS AND CERTIFICATION

I certify that the information provided in this application is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may result in denial of coverage or rescission of the policy. I understand that coverage is subject to the terms, conditions, limits and exclusions of the issued policy and that no coverage exists until a policy is issued and any required premium is paid.

I authorize the insurer to obtain and exchange such information as is reasonably required to underwrite this application, including loss history, claims information and other underwriting data. This authorization survives the signing of this application for the purpose of evaluating coverage and claims.

Applicant acknowledges that any change in the risk material facts prior to policy inception must be reported immediately to the insurer. Applicant agrees that the insurer may void or amend coverage for material misrepresentation or change in risk that increases the hazard insured against.

APPLICANT / INSURED SIGNATURE

Printed Name:

Signature:

Date:

What the Insurance Application and Exclusion Form Is

An Insurance Application and Exclusion Form is a structured document insurers and applicants use to request coverage and record specific perils, parties, or exposures that are deliberately excluded from a proposed policy. It combines applicant-identifying information, policy selections, material facts, and explicit exclusion clauses so underwriters can assess risk and quote appropriate terms. The form documents applicant representations and creates a clear record of items not covered, reducing future disputes about coverage scope while establishing the basis for underwriting decisions and premium calculations.

Why the Form Matters for Underwriting and Coverage Clarity

Used during application and policy review, this form clarifies which exposures are excluded and why, helping insurers set accurate premiums and applicants understand coverage limits. Clear exclusions reduce claims disputes, improve underwriting transparency, and document mutual expectations between insurer and insured.

Who Typically Completes or Receives This Form

Typical users who complete or receive this form include brokers, risk managers, and underwriting staff during placement or renewal processes.

Insurance agents and brokers handling client coverage requests and risk disclosures.
Corporate risk managers submitting exclusions for enterprise policies and certificate issuance.
Underwriters evaluating applications, exclusions, and premium adjustments based on declared risks.

Use depends on role: brokers initiate, applicants confirm, and insurers document decisions for compliance and audit trails.

Stepwise Process to Complete and Submit the Form

Follow these steps to complete and process the Insurance Application and Exclusion Form accurately securely.

01

Prepare: Gather applicant ID, policy details, and loss history.
02

Complete Form: Enter full applicant information and policy selections.
03

Specify Exclusions: Describe each exclusion clearly with dates and reasons.
04

Review & Submit: Have underwriter or broker verify before sending.

How to Configure an Online Workflow for eSubmission

Configure online workflow fields and routing for efficient e-submission and audit trail capture and compliance.

Field	Configuration
Signer Authentication	Email link with optional SMS code or KBA
Signing Order	Sequential routing or parallel signing options
Notify & Remind	Automatic reminders and expiration notices
Audit Trail	Timestamp, IP, and action log retained

Typical Document Flow from Completion to Policy Binding

This flow shows how the form moves from completion to underwriting and final policy issuance.

Upload: Attach completed form and supporting documents.
Assign: Route to underwriter, broker, or risk manager.
Review: Underwriter evaluates exclusions and requests clarification.
Bind: Issue policy terms, noting exclusions in declarations.

Platform and File Requirements for Digital Submission

Typical platform requirements for eSubmission include PDF support, secure TLS transport, and audit logging for chain-of-custody.

File Formats: PDF, DOCX, and scanned images accepted.
Security: TLS 1.2/1.3 in transit; AES-256 at rest.
Integrations: Connectors for Salesforce, NetSuite, Google Workspace.

Essential Sections You Should Expect on the Form

Primary sections of the Insurance Application and Exclusion Form highlight applicant data, policy selections, material disclosures, exclusion language, underwriting notes, and signatures.

Applicant Data

Collect legal name, business/entity type, tax identification number, mailing and physical addresses, contact phone/email, and authorized representative details. Accurate identification avoids TIN mismatches and ensures proper certificate issuance.

Policy Selections

Specify line of coverage, limits, deductibles, policy period, and whether coverage is occurrence-based or claims-made. These choices directly influence premium and exclusion applicability for specific exposures.

Material Disclosures

Disclose prior losses, pending litigation, hazardous activities, and any known facts that materially affect risk. Underwriters rely on full disclosure to price risk and avoid post-issuance rescission.

Exclusion Language

Draft clear exclusion clauses identifying covered perils, excluded parties, geographic or time boundaries, and cross-references to policy sections. Precise language reduces ambiguity during claims evaluation.

Underwriting Notes

Include underwriter observations, premium adjustments, endorsements required, and any contingency conditions. This internal section records the rationale behind coverage offers and exclusions and referral history.

Signatures

Provide printed names, titles, dates, and signature lines for all parties. State whether electronic signatures are authorized and include witness or notary sections when required by jurisdiction.

Security, Compliance, and Audit Considerations

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest.

Certifications: SOC 2 Type II; ISO 27001; PCI DSS.

HIPAA: BAA available; protected health information covered.

Audit Trail: Detailed timestamps, IPs, and action logs.

Authentication: Email, SMS, SSO, and advanced multi-factor options.

Access Controls: Role-based permissions and administrative logging.

Key Penalties and Risks from Incorrect or Omitted Information

TIN Errors: Backup withholding 24% (IRC rules).

Late Filing: Information return penalties under IRC §6721.

Intentional Misstatement: Higher penalties, no maximum per form.

Misrepresentation: Coverage voidable; rescission possible.

I-9 Violations: Civil fines $281–$2,789 per violation.

Notary Errors: Improper acknowledgment can invalidate filing.

Common Preparation Pitfalls to Avoid

Ambiguous exclusion language that omits dates or geographic limits, leading to disputes during claim adjudication and costly legal interpretation.
Incomplete applicant disclosures such as undeclared prior losses or pending suits which can trigger underwriting rescission or premium recalculation.
Mismatched names or incorrect TINs on the form causing delayed certificate issuance, backup withholding, or regulatory reporting complications.
Failing to obtain required witness or notary acknowledgments in jurisdictions that mandate them can render the exclusion unenforceable.

Timing Considerations and Typical Processing Windows

Key timing and deadlines affect submission, underwriting response, and tax or regulatory reporting obligations for insureds and insurers.

Submission Timing:

Submit upon application or when exclusion is negotiated.

Underwriter Response:

Expect initial review within 5–15 business days.

Policy Effective Date:

Exclusions apply from the effective date listed.

Certificate Requests:

Allow time to reissue certificates reflecting exclusions.

Record Retention:

Retain signed forms per company retention schedule and law.

Comparing eSignature Vendors for This Form (signNow Listed First)

Pricing comparison for common eSignature plans focusing on starting price, trial, bulk send, audit trail, and HIPAA availability.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions and Quick Answers

Answers to frequent questions about completing, signing, and storing the Insurance Application and Exclusion Form.

Need help? Contact support

Is notarization required for this form?
Notarization is not typically required for insurance application forms, but specific endorsements or state laws may mandate it. Remote online notarization (RON) rules vary by state; ESIGN/UETA do not override statutory notary requirements, so verify with the state notary authority.
Can parties sign electronically under ESIGN?
Yes in most cases. The ESIGN Act and UETA render electronic signatures legally enforceable if intent, consent, attribution, and record retention are present. Consumer-facing financial or health disclosures may require specific consent language under 15 U.S.C. §7001.
What supporting documents should be attached?
Include proof of identity, loss runs, prior-policy declarations, and any underwriting exhibits referenced in the exclusion clause. For healthcare-related exclusions, attach HIPAA authorizations or patient consents. Accurate attachments speed review and prevent underwriting delays.
Who is authorized to sign this form?
Authorized signers are the named applicant, an officer with signing authority for corporate applicants, or an authorized agent listed on company letterhead. Brokers or agents may countersign, but insured signature and printed name are required for legal attribution and ESIGN compliance.
How can the form be amended or revoked?
Amendments require written agreement signed by all parties, clearly marking changes and dates. To revoke, execute a written cancellation or replacement form and notify the insurer in accordance with policy terms and any applicable state notice requirements.
How long should signed forms be retained?
Keep signed Insurance Application and Exclusion Forms for the policy term plus a minimum of three years; retain longer when federal or state law requires it. For HIPAA-related records, follow 45 CFR §164.530(j) which requires six years.

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