Insurance Bind Packet

INSURANCE BIND PACKET

Applicant / Insured Information

Applicant Name:

Individual Corporation Partnership Trust Other

Date of Birth (if Individual): Month Day Year

Policy Details

Policy Number (if assigned):

Policy Period From: Month Day Year

Policy Period To: Month Day Year

Binder Information

Binder Effective Date: Month Day Year Time

Binder Expires On: Month Day Year

Coverages Requested

Select coverages to be bound and state limit where applicable.

General Liability Limit

Property Limit

Workers' Compensation State Jurisdiction

Commercial Auto Limit per vehicle

Professional Liability Aggregate Limit

Cyber Liability Limit

Endorsements and Special Conditions

Exclusions & Important Notices

The binder issued pursuant to this packet is expressly conditioned on the terms, exclusions and limitations of the policy form to be issued by the carrier. No coverage is effective beyond the binder expiration date or in excess of the maximum binder limit stated in this packet. The carrier's obligation shall be limited to those coverages expressly described above and any additional coverage or broader terms shall be effective only when set forth in a formal policy issued and countersigned by an authorized representative of the carrier.

The following exclusions are standard and apply unless otherwise agreed in writing: intentional acts, fraudulent acts, criminal conduct, war and nuclear hazard, and any other exclusions specifically set forth in the policy form. Any deviation from standard exclusions must be documented as an endorsement and countersigned by the carrier.

Loss Payee / Additional Insured

Beneficiary Designation (If Applicable)

Claims History

Any claims or losses in the past five (5) years? Yes No

Documentation Checklist

The following documents are required to finalize the policy. Check items submitted with this binder packet.

Signed Application Photo ID Loss Runs

Property Values / Inventory Drivers List Financial Statements

Premium Payment Terms

Binding of coverage under this packet is contingent upon receipt of the binder fee and any required premium deposit by the carrier or broker. If payment is not received prior to the effective time of this binder, the insurer's obligation to provide coverage is void ab initio. Any finance charges, fees, or installments will be set forth in the policy or invoice issued by the carrier.

Payment Method: Check Wire Transfer Credit Card

Representations, Warranties and Declarations

The undersigned represents and warrants that all statements made in this bind packet and any attachments are true, complete and material to the risk contemplated for underwriting. The applicant acknowledges that any material misrepresentation, omission, or concealment of fact may void coverage issued and permit the insurer to deny claims or rescind the policy to the extent permitted by law.

The applicant further agrees to cooperate fully with the insurer in the investigation and adjustment of any claim, to furnish any additional information reasonably requested, and to comply with all conditions precedent contained in the policy form.

Authorization to Bind / Certification

By signing below, the applicant authorizes the broker or carrier to bind coverage consistent with the terms set forth herein, subject to payment and the carrier's underwriting approval. This binder does not amend or expand coverage beyond that specifically described in this packet and any counter-signed endorsements. The applicant certifies that they have read and understand the terms, conditions and limitations stated above.

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