Insurance Application Mercury App

Insurance Application Mercury App

Applicant Name:

Applicant / Insured Information

Date of Birth:    Taxpayer ID (EIN or SSN):

Policy Details

Requested Policy Type:
Commercial Property   General Liability   Commercial Auto   Cyber Liability   Business Interruption

Policy Period (Requested): From to

Coverage Selection

Select specific coverages requested (enter limits where required):

Property Coverage — Limit: $

General Liability — Each Occurrence: $    Aggregate: $

Commercial Auto — Combined Single Limit: $

Cyber Liability — Limit: $

Exclusions and Limitations

The proposed policy will contain standard exclusions including, without limitation: intentional acts or criminal conduct by the insured; pollution and contamination unless specifically endorsed; war, military action and nuclear hazards; losses arising from professional services where professional liability coverage is not purchased; and any exclusion specific to cyber events where cyber coverage is not selected. Coverage is subject to policy language, limits, endorsements and conditions.

I acknowledge that I have read the foregoing exclusions and that any coverage provided will be subject to the full policy terms and applicable endorsements. Applicant acknowledges exclusions

Beneficiary Designation

Designate beneficiary(ies) to receive any payable proceeds under coverages that permit beneficiary designation. Percentages must total 100% for primary beneficiaries.

Prior Loss History

In the past 5 years, has the applicant had any claims or losses?   Yes   No

Declaration and Certification

The undersigned applicant certifies that the information provided in this application is true, correct and complete to the best of their knowledge. The applicant understands that this application, together with any supplemental information submitted to the insurer, will form the basis of any policy issued. The applicant further acknowledges a continuing duty to disclose material changes in risk and that failure to disclose material facts may result in denial of coverage, rescission of the policy, or adjustment of premiums and limits.

The applicant authorizes the insurer to obtain and verify pertinent information, including but not limited to claim history, loss runs, underwriting investigations, and credit or financial information where applicable for underwriting or risk assessment. The applicant agrees that premiums quoted are estimates and final premium will be determined in accordance with policy terms, underwriting rules and any applicable audits.

The applicant acknowledges that any coverage provided will be subject to policy terms, conditions, exclusions, endorsements and applicable deductibles. This application shall be governed by the laws of the jurisdiction in which the policy is issued. Any dispute arising from the application or policy shall be resolved in accordance with the policy's dispute resolution provision.

By signing below the applicant certifies under penalty of perjury that the statements made herein are complete and accurate.

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