Insurance Approval Form

INSURANCE APPROVAL FORM

Applicant / Insured Information

Month:   Day:   Year:

Policy Details

General Liability    Property    Auto    Homeowners    Life    Disability    Other:

Policy Period From: Month:  Day:  Year:   To: Month:  Day:  Year:

Coverage Selection

Select coverages to be included in approved policy (check all that apply):

Liability    Property Damage    Collision    Comprehensive    Theft    Personal Injury Protection    Medical Payments

Uninsured / Underinsured Motorist    Business Interruption    Flood    Earthquake    Cyber Liability    Other:

Exclusions and Acknowledgement

The following exclusions are standard to the approved coverage unless expressly endorsed: intentional acts, criminal activity, wear and tear, pollution not expressly covered, war and nuclear hazard, and losses excluded by statute. Any additional exclusions applicable to this risk are set forth below.

I acknowledge receipt of the exclusions above and understand that coverage will not apply to losses arising from the listed exclusions.

Applicant Initials:

Beneficiary Designation

Designate primary beneficiaries and allocation percentages. Percentages must total 100%.

Underwriting Conditions and Documentation

The following conditions and documents are required for issuance or continued effectiveness of this approval. Check each document submitted or required.

Signed Application    Inspection Report    Loss History / CLUE Report    Photographs of Risk    Receipts / Proof of Value

Police Report (if applicable)    Medical Records (if applicable)    Driver's License    Vehicle Registration

Approval Determination

Final determination by underwriting (check one):

Approved    Approved with Conditions    Declined

Certification and Authorization

By signing below, the Applicant certifies that all information provided on this form and in any supporting documentation is true, complete and accurate to the best of Applicant's knowledge. Applicant acknowledges that any material misrepresentation or omission may render the policy voidable or permit the insurer to deny claims, rescind coverage, or take other actions permitted by law and the policy.

Applicant authorizes the insurer and its representatives to obtain and verify underwriting, claims, credit and other consumer or commercial reports, and to obtain copies of records reasonably necessary to underwrite and service the policy. Applicant consents to disclosure of such information to reinsurers and service providers for underwriting, claims handling and fraud prevention.

This approval is effective only upon issuance of a policy document, receipt of required premium and satisfaction of any conditions set forth in this form or in underwriting correspondence. Premiums paid are subject to the terms, conditions and cancellation provisions of the policy.

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