Insurance Assurance Renewal Form

INSURANCE ASSURANCE RENEWAL FORM

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Number:    Policy Type:

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period From:    To:

Coverage Selection & Limits

General Liability    Limit: $

Property Damage / Physical Loss    Limit: $

Business Interruption    Limit: $

Automobile Coverage    Limit: $

Material Changes & Claims History

Have there been any changes in operations, occupancy, property, or risk exposure since the last policy period? No Yes

In the past policy period, have any claims, losses, or incidents occurred that may give rise to a claim under the policy? No Yes

Exclusions Acknowledgement

The following items are standard policy exclusions. By renewing, the applicant acknowledges these exclusions apply unless specifically endorsed.

Intentional acts and deliberate misconduct

War, insurrection, or hostile acts

Nuclear hazard and radioactive contamination

Wear and tear, gradual deterioration, or maintenance defects

Unlicensed operations or illegal activity

Beneficiary / Payee Designation

Relationship:    Percentage: %

Premium Payment & Billing

Payment Frequency: Annual Semi-Annual Monthly

Documentation Checklist (for insurer review)

Proof of prior loss history

Photographs of premises or property

Police report (if applicable)

Receipts, estimates, or invoices

Declaration, Authorization and Acknowledgements

I certify that the information supplied in this Insurance Assurance Renewal Form is true, complete, and correct to the best of my knowledge. I understand that any material misrepresentation, omission, or concealment of fact may be grounds for denial of renewal, cancellation of coverage, or rescission of the policy. I agree that this form, together with the existing policy declarations and endorsements, constitutes the basis for the insurer's consideration of renewal.

I authorize the insurer and its representatives to obtain information necessary to verify statements in this form, including inspection of premises, review of prior loss records, and verification of financial information. I further agree to promptly report any incident or circumstance that may give rise to a claim during the renewed policy period.

Premium payment for the renewed term is due in accordance with the billing schedule provided by the insurer. Failure to pay premium by the due date may result in termination of the policy in accordance with the policy terms. Renewal is subject to acceptance by the insurer; submission of this form does not guarantee renewal.

Fraud Warning: It is a criminal offense to knowingly furnish false, incomplete or misleading information to obtain insurance. Such conduct may result in denial of coverage, cancellation of the policy, and civil or criminal penalties as permitted by law.

Acknowledgement of Receipt

By signing below I acknowledge receipt of this Renewal Form and declare that I have reviewed and understand the statements contained herein. I understand that any additional endorsements or changes agreed to by the insurer will be issued in writing.

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