Insurance Application Documents

INSURANCE APPLICATION

This application is submitted to request issuance of an insurance policy. Completion of this form does not bind the insurer. The applicant warrants that all statements made herein are true and complete to the best of the applicant's knowledge and acknowledges that material misrepresentation or omission may result in denial of coverage or rescission of any policy issued.

Applicant / Insured Information

Applicant Name:

Individual    Corporation    LLC    Trust

Month: Day: Year:

Policy Details

Policy Period Effective Date: Month Day Year

Policy Period Expiration Date: Month Day Year

Coverage Selection

Select coverages requested (check all applicable and state desired limits where requested):

Property / Buildings    Limit:

Contents / Personal Property    Limit:

General Liability    Limit:

Comprehensive / All-Risk

Collision (Auto)    Deductible:

Personal Accident / Medical Payments    Limit:

Exclusions

The following are examples of standard exclusions that apply unless specifically endorsed: intentional acts or criminal conduct by an insured; loss arising from war, insurrection or nuclear hazard; losses caused by pollution or contamination except as otherwise provided; wear and tear, gradual deterioration, mechanical or electrical breakdown; losses arising from business pursuits not disclosed and accepted by the insurer; fraudulent claims. Additional exclusions may apply as set forth in the policy contract.

I acknowledge receipt and review of the exclusions as stated above: Applicant acknowledges exclusions

Beneficiary Designation (if applicable)

Claims History

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

Declarations and Authorizations

By signing below, the applicant certifies that the information provided in this application is true, complete and made in good faith. The applicant authorizes the insurer and its representatives to obtain and verify underwriting information, claims history, loss runs, credit information where permitted by law, and any other records relevant to the underwriting and administration of the policy, including medical records if applicable. A photographic or electronic copy of this authorization shall be as valid as the original.

The applicant understands that coverage, if issued, will be governed solely by the terms, conditions and exclusions of the issued policy. Receipt of premium or payment does not constitute acceptance of risk. The insurer reserves the right to accept, modify or reject this application. Any material misstatement, omission, or concealment of fact in this application may void coverage from inception.

Fraud Warning: Any person who knowingly submits a false statement or conceals a material fact with intent to defraud the insurer may be subject to civil and criminal penalties including denial of claim and policy rescission.

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