Insurance BOP Renewal Form

INSURANCE BOP RENEWAL FORM

Applicant / Insured Information

Policy Details

Current Policy Number:    Insurer:

Policy Type:

Policy Period — Effective:    Expiration:

Coverage Options — Select all that apply

Property (Building / Business Personal Property)

General Liability

Business Income (Business Interruption)

Crime / Employee Dishonesty

Equipment Breakdown

Cyber Liability (endorsed separately)

Hired & Non-Owned Auto Liability

Endorsements / Additional Coverages Requested

Exclusions — Acknowledgement

Standard exclusions that typically apply to a Business Owners Policy include, but are not limited to: flood, earthquake, war and hostile acts, nuclear hazard, intentional acts or willful misconduct by the insured, wear and tear, gradual deterioration, mechanical breakdown not covered by equipment breakdown, and pollution unless specifically endorsed. The insured is responsible for confirming specific exclusions on the policy declarations and endorsements.

I acknowledge that I have read and understand the common exclusions above and will review policy declarations and endorsements for the complete list of exclusions.

Changes in Operations / Exposures

Have there been any changes to business operations, occupancy, square footage, or new exposures since the prior policy period?    Yes    No

Claims History (Prior 12 Months)

Have any claims been made or losses occurred in the past 12 months?    Yes    No

Loss Payee / Beneficiary Information (if applicable)

Declaration and Certification

I certify that the information provided in this renewal form is complete, true and correct to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may result in modification or rescission of coverage or denial of a claim. I further authorize the insurer and its representatives to inspect the premises, operations and records reasonably necessary to evaluate this renewal, and to obtain claim or loss history from prior insurers or reporting agencies.

I acknowledge that renewal terms, coverage limits, endorsements, exclusions and premium are subject to underwriting review and may change from the prior policy period. I agree to notify the insurer or agent promptly of any material change in the information provided herein prior to the effective date of the renewal.

Fraud Warning: Any person who knowingly presents false or fraudulent information for the purpose of obtaining insurance coverage or payment of a claim may be subject to civil and criminal penalties under applicable law.

By signing below I attest that I am authorized to bind the named insured and I request renewal of the coverage(s) indicated on this form.

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