Insurance Carrier Packet

INSURANCE CARRIER PACKET

Carrier and Broker Information

Carrier Name:

Broker or Producing Agent:

Applicant / Insured Information

Individual    Corporation    LLC    Partnership    Other:

Policy Details

General Liability    Property    Auto    Professional Liability    Workers' Compensation    Other:

Policy Period: From to

Coverage Options and Limits

Select requested coverages and indicate any specific sub-limits or endorsements required.

General Aggregate Limit:

Per Occurrence Limit:

Property Damage Limit:

Pollution Liability    Employment Practices Liability    Cyber Liability

Exclusions and Limitations

The standard policy excludes losses arising from intentional acts, criminal activity, known prior acts, war and nuclear hazards, and any other exclusionary endorsements attached to this policy. Carrier may add additional restrictions by endorsement. Applicant must disclose all exposures that may reasonably affect underwriting.

Applicant Acknowledgement: I acknowledge I have read and understand the exclusions and will provide any requested information regarding potential excluded exposures.

Claims History / Loss Runs

Have there been any claims or incidents in the last five (5) years that could give rise to a claim?    Yes    No

Beneficiary / Additional Insured Information

Beneficiary / Additional Insured Name:

Underwriting Documentation Checklist

Provide copies or indicate included documents:

Completed and signed application

Loss runs (past 5 years)

Prior policy declarations

Financial statements (if requested)

Photos, plans, or site diagrams

Declarations and Certification

I certify that the information provided in this Insurance Carrier Packet is complete and accurate to the best of my knowledge. I understand that material misrepresentation or omission may be grounds for denial of coverage, rescission of the policy, or other legal remedy permitted by law. I authorize the carrier and its agents to obtain claim, credit, loss history, and other relevant information necessary for underwriting and administration of the policy. I agree to cooperate with reasonable requests for documents and to notify the carrier promptly of any material change in risk.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim or statement for payment of a loss is subject to criminal and civil penalties under applicable law.

Payment Authorization: By signing below, I authorize the carrier to issue premium invoices to the address provided and to use the premium payment method authorized on file. Coverage proposed is subject to receipt of premium and issuance of a policy or binder consistent with the carrier's underwriting guidelines.

Indemnity and Subrogation: If coverage is afforded and payment is made, the carrier shall be subrogated to the insured's rights of recovery as provided in the policy. The insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights.

I certify the foregoing statements are true and authorize the described actions.

Attachments and Carrier Instructions

Attach copies of all documents listed in the underwriting checklist. If additional information or special endorsements are required, carrier will provide written instructions. The carrier reserves the right to request supplemental documentation prior to binding coverage.

Sign Now