Insurance Compliance Supplement

INSURANCE COMPLIANCE SUPPLEMENT

Insured/Applicant Name:    Policy Number:

Applicant / Insured Information

Policy Details

Policy Type: General Liability Property Commercial Auto Professional Liability Cyber Liability

Policy Period: From to

Coverage and Limits — Selections & Notices

Indicate coverages declared for underwriting and compliance evaluation. Selections below modify the policy only if endorsed in writing by the insurer.

Contractual Liability — Limit indicated under Coverage Limit Employment Practices Liability — Requires prior written approval Fiduciary Liability — Subject to financial condition review Data Breach Response — Incident response vendor approval required

Exclusions, Material Changes, and Prior Notices

The insured must disclose any facts, circumstances or incidents that may give rise to a claim under the proposed policy or that materially increase exposure. Failure to disclose material information may result in rescission, denial of coverage, or adjustment of terms.

Yes    No

Beneficiary / Loss Payee Information

Claims Compliance and Prior Loss Information

Yes    No

Compliance Attestations & Authorizations

By selecting each box and signing below, the insured certifies the following under penalty of perjury and acknowledges the insurer's rights to verify information provided:

I certify that there are no undisclosed facts or circumstances that would materially affect the risk. I confirm premiums are current and that no material premium disputes exist. I have not been sanctioned, excluded, or otherwise restricted by any government or regulatory authority that would prohibit coverage. I represent that the insured complies with applicable anti-money laundering and anti-corruption laws and has not engaged in conduct that would create material regulatory exposure. I authorize the insurer and its agents to obtain and verify any information necessary for underwriting, claims handling, or regulatory compliance, including consumer reports and loss history.

Attachments Checklist

Provide or indicate the documents attached to this supplement:

Loss runs (most recent 3-5 years) Financial statements (most recent fiscal year) Corporate formation documents / ownership records Prior policy declarations and endorsements Other:

Declaration and Signature

I certify that the information supplied in this Insurance Compliance Supplement is true, complete, and accurate to the best of my knowledge and that no material facts have been omitted. I understand that any intentional misstatement, omission or concealment of a material fact may constitute fraud and may be grounds for denial of coverage or rescission of the policy. I authorize the insurer to obtain any information necessary to evaluate this application, to share information as required for underwriting, claims handling, or regulatory compliance, and to retain copies of any supporting documents submitted.

The undersigned acknowledges that representations made herein become part of the policy application and may be relied upon in the issuance and maintenance of coverage.

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