Insurance Association Liability Form

INSURANCE ASSOCIATION LIABILITY FORM

Applicant / Insured Information

Policy Details

Requested Policy Type: General Liability Directors & Officers (D&O) Professional Liability

Proposed Policy Period: From to

Coverage Selection and Limits

General Liability Limit:

Directors & Officers (D&O) Limit:

Professional Liability (Errors & Omissions) Limit:

Automobile Liability Limit:

Exclusions and Limitations

The following exclusions are standard and will apply unless otherwise agreed in writing. Applicant acknowledges review of the exclusions below and understands that coverage will not respond to loss arising from:

• Intentional wrongful acts, fraud, criminal conduct, or willful violation of statute;
• Pollution, asbestos, lead or mold unless specifically endorsed;
• War, nuclear hazard, and acts of terrorism subject to applicable law and endorsement;
• Professional services not expressly included in the policy wording; and
• Claims or circumstances known prior to the policy inception date.

Applicant acknowledges the standard exclusions by checking below:

I acknowledge and accept the standard policy exclusions as stated above.

Claims and Loss History

Has the association reported any liability claims, suits, or incidents in the past five (5) years? Yes No

Beneficiary Designation

Designated beneficiary for policy proceeds, indemnity or subrogation recoveries:

Declaration and Certification

The undersigned certifies that the information contained in this application is true, complete and correct to the best of their knowledge. The applicant further warrants that no material facts have been suppressed or misstated and agrees that this application shall be the basis of and incorporated into any resulting policy.

The applicant authorizes any insurer to obtain and exchange underwriting information, claim history and loss runs relevant to this application. The applicant understands that any false statement made with the intent to deceive may result in denial of coverage or rescission of the policy.

The applicant acknowledges that coverage, limits, exclusions and conditions will be governed by the policy terms and endorsements issued. No agent or broker has authority to modify coverage other than by written endorsement signed by an authorized representative of the insurer.

By checking this box I represent that I am authorized to bind the association and that I have read, understand and agree to the foregoing declarations and certifications.

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