Insurance Application Pack

INSURANCE APPLICATION PACK

Applicant / Insured Information

Individual Corporation LLC Trust

Policy Details

Policy Type: Property Liability Auto Life Health

Policy Period: From to

Coverage Options

Optional coverages (select all that apply):

Theft / Burglary Coverage Flood Coverage (subject to underwriting) Earthquake Coverage Business Contents / Commercial Property Personal Injury Liability Medical Payments

Exclusions

The proposed policy does not provide coverage for loss or liability arising from: war or hostile acts; nuclear reaction, radiation or radioactive contamination; intentional acts or deliberate non‑compliance by the insured; gradual deterioration, wear and tear, corrosion and inherent vice; pollution unless specifically endorsed; criminal acts by the insured; fraudulent claims; and losses excluded by any applicable endorsement. Additional exclusions may apply in the policy document. The insurer may deny coverage or rescind the policy for material misrepresentation in this application.

Claims History & Loss Information

Have you or any person proposed for insurance had any claims, losses, or suits in the last five (5) years? Yes No

Beneficiary Designation

Beneficiary for life or payable-on-death provisions (if applicable). Attach additional schedule if more than one beneficiary.

Documentation Checklist

Please attach the items below as applicable (check all attached).

Copy of driver's license / photo ID Photographs of insured property / vehicle Purchase receipts or proof of ownership Police report (if applicable) Prior insurance declarations (if available)

Declarations, Certification & Authorization

I declare that the statements made in this application are true and complete to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may result in denial of coverage, rescission of the policy, or voiding of claims. I authorize the insurer, its representatives, and any claims or investigative representatives to obtain and exchange information necessary to underwrite or administer coverage, including claims, loss history, and other underwriting information. This authorization includes obtaining information from prior carriers, loss databases, and other insurers.

I further acknowledge and agree that completion of this application does not bind coverage; coverage is effective only upon issuance of an insurer's policy and receipt of premium where required. I agree to pay premiums when due and to comply with policy terms, conditions and timely notice requirements. I understand that any intentional false statement in this application may subject me to civil or criminal penalties under applicable law.

By checking this box I certify the truthfulness and completeness of all answers and authorizations in this application.

Notice Regarding Fraud

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance, may be subject to civil or criminal penalties, including denial of coverage and restitution. Fraudulent acts will be investigated and referred for prosecution where appropriate.

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