Insurance Clearinghouse Application

Insurance Clearinghouse Application

Applicant Name:

Applicant / Insured Information

Entity and Tax Information

Entity Type: Individual Corporation LLC Partnership Non-Profit Other:

Policy Details

Policy Period: From to

Coverage Options (select applicable)

General Liability
Professional Liability / E&O
Property (Commercial)
Cyber Liability
Workers' Compensation
Automobile Liability
Umbrella / Excess Liability
Other:

Exclusions and Limitations

The Clearinghouse operates as an administrative and underwriting data exchange. Submission of this application does not bind coverage. The Clearinghouse and participating insurers may apply standard and specific exclusions consistent with underwriting rules. Known typical exclusions include but are not limited to: intentional acts, punitive damages where uninsurable by law, acts of war, and liabilities arising from criminal conduct. Applicant must disclose all facts material to underwriting. Failure to disclose material facts may permit rescission, denial of claims or retroactive policy adjustments.

Beneficiary Designation

Designate primary beneficiaries for any return premium or claim proceeds as applicable.

Claims History and Loss Runs

Have you had any claims, suits or incidents in the last five years that could give rise to a claim? Yes No

Attach loss runs for the past five (5) years when available. The Clearinghouse may request additional documentation for underwriting evaluation.

Documentation Checklist

Completed Application
Signed Authorization to Release Records
Copies of Current Policies / Declarations
Loss Runs (last 5 years)
Financial Statements (if requested)
Proof of Identity (government ID)
Other attachments:

Authorization and Certification

By signing below, the Applicant certifies that all statements in this application are true, complete and accurate to the best of Applicant's knowledge. Applicant authorizes the Clearinghouse and participating insurers and their agents to obtain and share underwriting, claims and loss information, credit and financial information, and any other relevant data with each other and with authorized service providers for underwriting, placement, administration and claims handling purposes. This authorization includes the right to obtain consumer and commercial credit reports where permitted by law.

Applicant further acknowledges that submission of this application is an offer to the Clearinghouse for administrative processing and underwriting; no coverage is bound until a policy is issued and the required premium is paid. Applicant agrees to notify the Clearinghouse promptly of any material change in risk circumstances between the date of this application and the effective date of any policy issued. Applicant agrees to indemnify and hold harmless the Clearinghouse and participating insurers against losses arising from Applicant's misrepresentations, intentional omissions, or fraudulent statements.

Applicant acknowledges receipt of and consents to the Clearinghouse's use of Applicant data for policy placement, premium collection, regulatory reporting and risk management. Applicant understands that certain data sharing is required for placement with participating insurers and that state-specific notices may apply where applicable.

Additional Remarks

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