Insurance Application Kinsale

INSURANCE APPLICATION - KINSALE

Applicant / Insured Information

Individual Partnership Corporation LLC Other

Policy Details

Coverages Requested

General Liability   Limit:

Commercial Property   Limit:

Professional Liability (Errors & Omissions)   Limit:

Cyber Liability   Limit:

Commercial Auto   Limit:

Inland Marine / Equipment Floater   Limit:

Prior Insurance & Loss History

Has the applicant had any claims, losses, or suits in the past five (5) years?    Yes    No

Exclusions and Acknowledgements

Applicant acknowledges that coverage, if issued, will be subject to standard exclusions including but not limited to: intentional or criminal acts by the insured, punitive damages where uninsurable by law, war and hostilities, nuclear hazard, wear and tear, pollution arising from excluded operations, and losses excluded by any specific endorsement. The insurer reserves the right to add additional underwriting exclusions based on risk evaluation.

Applicant initials acknowledging exclusions and review of underwriting considerations:   

Beneficiary Designation (if applicable)

Beneficiary 1 Name:   Relationship:   %:

Beneficiary 2 Name:   Relationship:   %:

Declarations & Certification

By signing below, the applicant certifies that all statements and answers contained in this application are true, complete and correctly recorded to the best of the applicant's knowledge. Applicant understands that any material misrepresentation, omission or concealment may result in denial of coverage, rescission, or cancellation of the policy issued. Applicant authorizes Kinsale and its representatives to obtain and verify information, including but not limited to claims history, credit information where permitted, loss runs and other underwriting data, and to provide such information to reinsurers and authorized representatives for underwriting and claim handling purposes.

Applicant agrees that coverage will be bound only upon issuance of a policy by Kinsale (or underwriter acting for Kinsale). Premium and payment terms will be stated in the policy and any premium presented prior to policy issuance shall be applied in accordance with the policy terms. Receipt of premium does not constitute acceptance of risk or waiver of underwriting review.

Fraud Warning: Any person who knowingly and with intent to defraud an insurer files an application or statement of claim containing false, incomplete or misleading information may be guilty of insurance fraud and subject to civil and criminal penalties in accordance with applicable law.

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