Insurance Application & Policy

INSURANCE APPLICATION & POLICY

Applicant / Insured Information

Applicant Name:

Policy Details

Policy Type:

Premium Payment Frequency: Annual Semi-Annual Quarterly Monthly

Coverage Selection

Indicate coverages requested and state limit(s) and deductible(s) where applicable.

Property Coverage   Limit:   Deductible:

General Liability   Limit:   Deductible:

Auto / Fleet Coverage   Limit per vehicle:

Professional Liability (E&O)   Limit:

Business Interruption   Limit:

Exclusions and Limitations

The policy issued pursuant to this application shall be subject to exclusions, endorsements, and limitations set forth in the policy form. Unless expressly agreed in writing in an endorsement signed by an authorized representative of the insurer, coverage will not apply to loss or liability arising out of:

(a) intentional acts or willful misconduct; (b) known claims or circumstances not disclosed in this application; (c) war, invasion, insurrection or nuclear hazard; (d) fraudulent or criminal acts by an insured; (e) pollution, unless specifically endorsed; (f) professional acts and omissions except where Professional Liability is selected and endorsed.

Beneficiary Designation (if applicable)

Primary Beneficiary Name:

Declarations and Certification

I certify that the information contained in this application is true and complete to the best of my knowledge and belief. I understand that this application becomes part of any policy issued and that any material misrepresentation, omission or fraud in relation to this application may give rise to denial of coverage or rescission of the policy.

I authorize the insurer and its representatives to obtain, verify and exchange relevant information, including but not limited to claims history, underwriting and inspection reports, and other information reasonably necessary to evaluate this application and administer any policy issued. I understand that premiums are subject to audit and adjustment in accordance with the policy terms.

The issuance of coverage is conditional upon acceptance by the insurer and payment of premium. Coverage, endorsements, limits, and conditions will be those set forth in the issued policy documents. Acceptance of any premium does not waive the insurer's rights to rescind or deny coverage where permitted by law and policy provisions.

By checking this box I affirm that I have read and understood the declarations and certify the statements above are accurate.

Notice Regarding Fraud and Cancellation

Fraudulent statements or intentional concealment of material facts may void coverage for the insured and may be a criminal offense. The insurer reserves the right to cancel coverage in accordance with policy terms and applicable law. Premiums for canceled policies will be adjusted pro rata unless otherwise specified in the policy.

Additional Information / Statement of Risk

Payment Authorization

I authorize the insurer to charge any premium payment owed pursuant to this application or policy to the payment method provided to the insurer. Payment of the initial premium does not bind the insurer to issue a policy except as provided in writing by the insurer.

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