Insurance Bodily Injury Coverage Form

INSURANCE BODILY INJURY COVERAGE FORM

Insurer and Policy Information

Insurer Name:

Policy Number:    Agent / Broker:

Auto Liability    General Liability    Other:

Policy Period Effective:    Expiration:

Named Insured / Applicant

Date of Birth:    Phone:    Email:

Bodily Injury Coverage Selection

Coverage Selected:    Bodily Injury Liability    Medical Payments (Optional)

Per Person Limit:    Per Accident / Occurrence Limit:    Combined Single Limit:

Deductible (if applicable):    Annual Premium:

Exclusions, Conditions and Limitations

The Insurer will not be liable for bodily injury losses excluded under the policy. By initialing each exclusion below the Named Insured acknowledges receipt and understanding of these limitations:

Intentional acts or willful misconduct by the insured

Bodily injury arising from business or professional operations not listed as covered

Injury sustained while insured is under influence of drugs or alcohol in violation of law

War, declared or undeclared, or acts of terrorism as defined in the policy

Condition: Coverage is conditioned upon payment of premium when due, cooperation with the insurer in defense and investigation of claims, truthful disclosure of material facts, and compliance with the policy's notice and proof-of-loss requirements. Failure to comply may result in denial or rescission of coverage.

Subrogation: If the insurer pays for a loss, the insurer may pursue subrogation against any third party responsible for the loss. The insured must preserve the insurer's subrogation rights and cooperate in any recovery efforts.

Optional Medical Payments / Add-Ons

Medical Payments coverage selected    Limit:    Deductible:

Beneficiary Designation (for Medical Payments or Related Benefits)

Beneficiary Name:

Relationship to Insured:    Percentage of Benefit:

Claims Reporting (Initial Notice)

Estimated Medical Expense:    Police Report Filed: Yes

Witnesses / Contact Information:

Declaration and Certification

By signing below the Named Insured certifies that the information provided in this form is true, complete, and correct to the best of the insured's knowledge. The undersigned understands and agrees that:

1. Coverage is subject to all terms, conditions, limitations and exclusions of the policy and the insurer's underwriting guidelines.
2. Material misrepresentation, fraudulent statements, or concealment of material facts may void coverage and may result in denial of claims and/or rescission of the policy.
3. The insured must cooperate in the investigation, defense and settlement of claims and must provide timely notice and proof of loss as required by the policy.
4. Premium quoted or paid may be adjusted for audit, changes in exposure, or underwriting review consistent with policy terms.

The insured authorizes the insurer and its representatives to obtain and use loss history, driving records, and other underwriting information necessary to evaluate coverage and claims. The insured also authorizes release of information to entities involved in claim handling and subrogation.

Sign Now