Insurance Businessowners Application Form

INSURANCE BUSINESSOWNERS APPLICATION FORM

Applicant Information

Applicant / Insured Name:

Employer Identification Number (EIN):    Phone:

Email for correspondence:

Ownership / Principal

Date of Birth:    % Ownership:

Business Information

Year Business Established:    Number of Full-Time Employees:    Annual Gross Revenue:

Protection Class:    Sprinklered:    Burglar/Fire Alarm:

Policy Details Requested

Policy Type Requested:

Desired Effective Date:    Desired Expiration Date:

Estimated Annual Premium:

Coverages Requested (check all that apply)

  Building Coverage

  Business Personal Property / Contents

  General Liability

  Business Income / Extra Expense

  Equipment Breakdown

  Crime / Employee Dishonesty

  Cyber Liability (optional endorsement)

Exclusions, Limitations and Important Notices

The coverage sought by this application is subject to the insurer's policy forms, endorsements, terms, conditions and exclusions. Notwithstanding any proposal, coverage will not include loss, damage or liability arising directly or indirectly from:

• War, hostilities, insurrection, nuclear hazard, and government seizure or destruction of property.
• Intentional acts or dishonest acts of the insured, or criminal acts by insured parties.
• Pollution or contamination except as may be specifically endorsed; wear and tear, gradual deterioration, insects or vermin.
• Loss of electronic data except as provided by a specific cyber or data endorsement.
• Losses excluded by ordinance or law, except as may be endorsed for increased cost of construction.

Additional exclusions, sublimits and conditions may apply by endorsement. Any quotation or binder issued prior to policy issuance is conditional and may be rescinded if material facts or representations in this application are incomplete, inaccurate or materially changed prior to inception.

Prior Insurance and Loss History

  No prior losses to report

Attachments Checklist

  Loss runs for the prior 5 years

  Financial statements (if requested)

  Floor plans, lease agreements, tenant information

  Other supporting documentation (describe below)

Declarations, Representations and Authorization

The Applicant declares that the statements contained in this application and any attachments are full, complete and true to the best of the Applicant's knowledge. The Applicant understands and agrees that:

1. All material representations made in this application shall become part of any policy issued and that any material misrepresentation, concealment or omission may give the insurer grounds to deny coverage, rescind the policy, or void coverage from inception.
2. Coverage will be subject to the insurer's policy language, endorsements, limits, conditions and exclusions. No coverage is bound except by a written binder issued by the insurer or its authorized representative.
3. The Applicant authorizes the insurer and its representatives to obtain and verify information regarding the Applicant's prior insurance, claims history, credit information and financial condition, and to inspect the described premises and operations at reasonable times.
4. The Applicant authorizes third parties, including prior carriers, to release claim and underwriting information to the insurer.

Fraud Warning: Wherever applicable by law, any person who knowingly submits an application containing false, deceptive or fraudulent material information may be subject to criminal or civil penalties, including denial of coverage and forfeiture of benefits.

By signing below, the Applicant certifies that the statements made herein are true and authorizes the insurer to use and disclose information in accordance with the declarations above.

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