Insurance Broker Package

INSURANCE BROKER PACKAGE

Broker Information

Applicant / Insured Information

Individual Corporation Limited Liability Company (LLC) Partnership Other:

Policy Summary & Recommended Coverage

Policy Type(s) Recommended:

General Liability Professional Liability / Errors & Omissions Property Commercial Automobile Cyber Liability Workers' Compensation Other:

For each selected policy, indicate the proposed coverage limit, deductible and annual premium.

Policy Period: From to .

Annual Semi-Annual Quarterly Monthly

Coverage Options & Endorsements

The broker recommends the following endorsements and optional coverages. Indicate selection by checking each box.

Additional Insured Endorsement Waiver of Subrogation Primary and Non-Contributory Data Breach / Cyber Endorsement Hired and Non-Owned Auto Coverage

Exclusions & Important Limitations

The following exclusions commonly apply to the recommended coverage. The insured acknowledges these standard exclusions and understands that additional insurer-specific exclusions may apply.

• Intentional acts, fraud or criminal conduct.
• Pollution and environmental damage except where specifically endorsed.
• War, nuclear hazard, and acts of government or civil authority.
• Contractual liability beyond that which can be assumed by endorsement.
• Prior known claims or circumstances not disclosed at inception.

I acknowledge that I have reviewed the exclusions listed above and understand that those items are not covered unless specifically added by endorsement.

Insured Initials:

Beneficiary Designation

Designate beneficiary(ies) for proceeds where applicable (life-contingent or similar coverages). Percentages must total 100%.

Claims History

In the prior five years, has the insured had any claims, suits, incidents or potential claims that might be covered under the proposed policies?

Yes No

Authorization & Privacy Consent

The undersigned authorizes the broker to obtain underwriting, claims and loss information from prior carriers, employers, or third parties as necessary to procure insurance. The undersigned further authorizes release of such information to insurers for underwriting and claim handling purposes.

I authorize the release of my claims and underwriting history:

Broker Duties, Compensation & Limitation of Liability

The broker will act as an agent of the insured for placement and servicing of policies and will present coverages from insurers selected in the broker's professional judgment. The broker does not guarantee insurer performance or claims payment. Placement is subject to insurer underwriting acceptance and contractual terms of issued policies.

Broker compensation: commission from insurer and/or broker fee payable by insured. Broker fee: . Any commission split or referral arrangement will be disclosed upon request.

Cancellation, Non-Payment & Mid-Term Changes

The insured acknowledges that cancellations for non-payment or material misrepresentation may result in early termination of coverage and subject to premium adjustment or return premium per the issuing insurer's terms. Requests to change coverage mid-term must be submitted in writing to the broker and are subject to insurer approval.

Declarations & Certification

By signing below, the undersigned declares that the statements made in this Insurance Broker Package are true, complete and accurate to the best of the undersigned's knowledge. The undersigned understands that any material misrepresentation or omission may be the basis for rescission or denial of coverage. The undersigned consents to binding communications between the broker and insurers and acknowledges receipt of broker disclosures regarding compensation and duties.

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