Insurance Client Profile

INSURANCE CLIENT PROFILE

Applicant / Insured Information

Date of Birth:   Gender:

Phone:   Email:

Entity / Ownership

Please indicate insured entity type (check all that apply):

Individual    Joint    Corporation    Trust

Policy Details

Coverage Amount:   Deductible:   Premium (annual):

Policy Number:

Policy Period From:   To:

Coverage Selections

Indicate coverage to be applied under the policy (check all requested):

Property / Buildings    Contents / Personal Property    General Liability

Automobile    Umbrella / Excess Liability    Professional Liability (E&O)

Exclusions — Acknowledgement

The applicant acknowledges that standard policy exclusions may apply, including but not limited to: intentional acts, wear and tear, fraudulent acts, nuclear hazard, war, and pollution unless specifically endorsed. Applicant must read policy terms upon issuance.

I acknowledge I have read and understand the common exclusions and any endorsements I request may modify coverage and premium.
Acknowledged

Beneficiary / Payee Designation

Designate primary beneficiary(ies) for applicable coverages (percentages must total 100% where required).

Relationship:   Percentage: %

Relationship:   Percentage: %

Relationship:   Percentage: %

Total beneficiary allocation confirmed: Confirm percentages total 100% when required by policy

Prior Insurance & Claims History

Have you had any claims, losses, or cancellations in the past five (5) years?    Yes    No

Additional Insureds / Mortgagee / Loss Payee

Authorization, Declarations and Certification

By signing this Insurance Client Profile, the applicant certifies that all information provided is true, complete and correct to the best of the applicant's knowledge. The applicant understands that intentional misrepresentation or omission of material facts may result in denial of coverage, rescission of the policy, or other remedies provided under law.

The applicant authorizes the insurer and its representatives to obtain and verify information from other insurers, consumer reporting agencies, loss history databases, employers, and other legitimate sources as necessary for underwriting, rating, and claims handling. The applicant acknowledges that such information may be shared with reinsurers and administrators for policy issuance and servicing.

The applicant agrees to promptly report any material change in risk, occupancy, operations, or other facts relevant to the coverage requested. Coverage is not bound or effective until the insurer issues a policy or binder in writing and payment of any required premium or deposit is accepted.

I declare under penalty of perjury under the laws of the applicable jurisdiction that the foregoing is true and correct.

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