Insurance CIU Application

INSURANCE CIU APPLICATION

Section A — Applicant / Insured Information

Applicant Name:

Date of Birth:

Social Security Number / Tax ID:

Primary Phone: Email:

Occupation / Title:

Section B — Policy Details

Requested Policy Type:

Deductible: Annual Premium (estimated):

Policy Period From:   To: 

Section C — Exclusions, Limitations and Special Conditions

The Applicant acknowledges that coverage will be subject to standard policy exclusions and any specific endorsements or limitations imposed by the insurer. Common exclusions include but are not limited to: intentional acts by the insured; losses arising from unreported prior damage; war, nuclear hazard, and fraudulent acts; wear and tear or lack of maintenance; punitive damages where unenforceable by law. The final scope of coverage is determined by the issued policy language.

Section D — Beneficiary Designation

Relationship: Percentage:

Section E — Underwriting & Claims History

Have you or any proposed insured sustained any loss or filed any claim in the last five years involving the coverages applied for?

Has any insurer cancelled, declined to renew, or refused coverage to you in the past five years?

Section F — Certification, Authorization and Fraud Warning

The Applicant certifies that the information contained in this application is true, complete and accurate to the best of the Applicant's knowledge. The Applicant understands that any material misstatement or omission may constitute grounds for denial of coverage or rescission of any issued policy. The Applicant authorizes the insurer, its affiliates, and their authorized representatives to obtain information from public records, previous insurers, medical providers (where applicable), and other third parties for underwriting, claims handling and fraud prevention, subject to applicable laws and regulations.

The Applicant further acknowledges that issuance of a policy is subject to satisfactory underwriting review and receipt of premium. No coverage exists until a policy is issued in writing and premium paid. The Applicant agrees to promptly provide additional information or documents requested by the insurer during underwriting or claim investigation.

Fraud Warning: Where permitted by law, any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud and subject to civil or criminal penalties.

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