Insurance Coalition Renewal Form

Insurance Coalition Renewal Form

Member / Insured Information

DOB:

Entity Type: Individual Corporation LLC Nonprofit Government/Municipality

Policy Details — Renewal Information

Coverage Amount: $    Deductible: $    Annual Premium: $

Policy Period: From to

Coverage Selection

Select coverage components to be renewed (check all that apply):
General Liability Property (Buildings / Contents) Workers' Compensation Cyber Liability Directors & Officers Liability Professional Liability / Errors & Omissions

Claims History and Loss Information

Within the last five (5) years, has the member reported any claims, incidents, or potential claims to the coalition or insurer?    Yes No

For the most recent claim: Date of Loss:

Estimated amount paid or reserved for that claim: $

Documentation attached: Police report Photographs Repair estimates Invoices / Bills

Material Change Declaration

Has there been any material change in exposures, operations, property, or use of premises since the prior renewal?    Yes No

Exclusions and Acknowledgements

The member acknowledges that renewal is subject to the coalition's underwriting criteria and the policy form in force. Standard exclusions applicable to coalition coverage may include, but are not limited to: war and terrorism (where excluded by endorsement), intentional acts, fraudulent acts, pollution not otherwise covered, and criminal acts by insured parties. The undersigned warrants that no information provided herein is false or misleading.

I acknowledge receipt and review of standard exclusions and understand that such exclusions may apply to renewed coverage:    Acknowledged

Beneficiary Designation (If Applicable)

Complete beneficiary information for any life or death benefit provided through coalition membership.

Declaration and Certification

By signing below, the authorized representative certifies that the statements and answers contained in this renewal form are complete and true to the best of their knowledge. The member authorizes the coalition and its representatives to obtain and release loss history, underwriting information, and other data necessary to evaluate eligibility for renewal. Material misrepresentation, omission, or fraud may result in denial of coverage, rescission of policy, or voiding of coverage in accordance with policy terms and applicable law.

The member acknowledges that renewal is subject to final underwriting acceptance and may be subject to revised terms, premiums, endorsements, or exclusions. Submission of this renewal form does not bind coverage until confirmed in writing by the coalition or its authorized representative.

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