Insurance Assumption Form

INSURANCE ASSUMPTION FORM

Parties and Policy Identification

Original Insurer:

Assuming Insurer:

Insured / Policyholder Name:

Coverage and Financial Terms

Coverage Limit(s): $    Deductible: $

Annual Premium: $    Assumption Effective Date:

Representations, Assumption and Conditions

Recital: Original Insurer and Assuming Insurer agree that, subject to the terms of this form and any separate assumption agreement executed by insurers, the Assuming Insurer will assume the rights, obligations and liabilities under the policy identified above, but only to the extent expressly set forth herein.

Assumption of Obligations: Upon the Assumption Effective Date, the Assuming Insurer shall assume defense and indemnity obligations for covered claims arising within the scope of assumed coverages. Assumption shall be limited to claims first reported on or after the Assumption Effective Date unless otherwise agreed in writing.

Transfer of Rights: The Insured hereby consents to the transfer of policy rights, including but not limited to coverage, claim handling and premium adjustments, to the Assuming Insurer as of the Assumption Effective Date. The Insured represents that all statements in this form are true and complete to the best of the Insured's knowledge.

Premium and Adjustment: Any premium allocation, audit adjustments, return premiums or additional premiums attributable to the period of risk assumed shall be determined by agreement of the insurers. The Insured acknowledges that premium adjustments may result from the assumption and agrees to permit the insurers to make customary audits and adjustments.

Claims Handling and Subrogation: The Assuming Insurer shall have the right to control the defense and settlement of claims subject to any reservation of rights or consent provisions required by the original policy. The Assuming Insurer reserves all subrogation rights against responsible third parties to the extent of payments made following assumption.

Representations and Warranties of Insured: The Insured warrants that there are no known circumstances likely to give rise to a claim not disclosed to the Original Insurer, and that the Insured has provided truthful information relevant to underwriting and loss history.

Exclusions and Limitations

The following exclusions apply to the assumption unless separately agreed in writing by the parties. Check applicable exclusions that the Assuming Insurer specifically disclaims:

Required Documentation Checklist

Beneficiary / Payee Designation (if applicable)

Beneficiary 1 Name:

Beneficiary 2 Name:

Notices, Governing Law and Miscellaneous

Notices: All notices required under this assumption shall be in writing and delivered to the addresses supplied on this form or to any successor address provided in writing. Notice is effective upon receipt.

Governing Law: This form shall be construed in accordance with the laws of the jurisdiction governing the underlying policy unless otherwise agreed in writing. Any disputes arising under this form shall be subject to the exclusive jurisdiction set forth in the underlying policy or, if none, the jurisdiction where the Insured is domiciled.

Severability: If any provision of this form is held unenforceable, the remaining provisions shall continue in full force and effect to the maximum extent permitted by law.

Certification and Consent of Insured

I, the undersigned Insured, certify under penalty of perjury that all information provided in this Insurance Assumption Form is true and complete. I consent to the assumption of the identified coverages by the Assuming Insurer on the terms stated herein and authorize the Original Insurer to disclose underwriting, premium and claims information necessary to effectuate the assumption. I understand that this consent does not modify coverage other than as expressly described in this form or by separate written agreement between the insurers.

Sign Now