Insurance Corporate OCI Acknowledgment Form

INSURANCE CORPORATE OCI ACKNOWLEDGMENT FORM

Applicant / Insured Information

Corporate Name:

Contact Phone:     Contact Email:

Entity Type

Select the corporate entity type (check one): Corporation     Limited Liability Company (LLC)     Partnership     Other:

Policy Details

Insurer Name:

Policy Number:     Policy Type:

Organizational Conflicts of Interest (OCI) Disclosure

Purpose: This form documents known organizational conflicts of interest (OCI) that could affect underwriting, claims handling, or loss mitigation. The undersigned corporate entity must disclose any relationships, ownership interests, contractual arrangements, or financial interests that could reasonably create an incentive to impair impartiality or objectivity in connection with the policy identified above.

Ownership interests in vendors, suppliers, or service providers to the insurer or insured
Current or recent contractual relationships with the insurer, claims administrators, or brokers
Shared board members or executive officers with vendors or the insurer
Loans, guarantees, or financial instruments tied to insurer-affiliated entities
Pending litigation or regulatory proceedings involving insurer or affiliated entities
Ownership, control, or material affiliation with a captive insurer or affiliated insurance entity
Exclusive or material brokerage or referral agreements that may influence placement
Other OCI:

Coverage and Exclusions Acknowledgment

By checking the boxes below the undersigned acknowledges awareness of the principal coverage and exclusion provisions of the policy identified above.

General liability coverage applicable as stated in the policy declarations
Professional or management liability coverage (if applicable)
Cyber liability coverage (if applicable)
Exclusion for contractual liability as specified in policy terms
Exclusion for war, nuclear, or government action where applicable
Pollution or environmental exclusions where specified in policy wording

Beneficiary / Payee Information (if applicable)

Representations, Warranties and Certification

The undersigned certifies that the information provided in this form is true, complete, and accurate to the best of the corporate entity's knowledge. The undersigned further represents and warrants that:

1. The corporate entity has conducted a reasonable inquiry into potential organizational conflicts of interest and has disclosed all known conflicts that could materially affect the insurer's underwriting, claims handling, or risk assessment obligations.
2. The corporate entity will promptly notify the insurer in writing of any material change in circumstances, newly discovered conflicts, or additional information that would alter any disclosure made on this form.
3. The corporate entity consents to the insurer's reasonable verification of disclosed information, including the review of contracts, financial arrangements, and relevant corporate records, subject to applicable confidentiality protections.
4. False or misleading statements, or the intentional omission of material facts, may constitute a breach of the policy, give rise to civil or criminal penalties under applicable law, and may result in denial of coverage or rescission of the policy.

Contracts or agreements evidencing disclosed relationships
Financial statements or schedules (pertinent to disclosed OCI)
Board minutes or resolutions reflecting affiliations
Other supporting documentation:

Acknowledgment and Signature

The undersigned, on behalf of the corporate entity identified above, acknowledges receipt of this form and confirms that the corporate entity has authority to make the statements and certifications contained herein. The corporate entity authorizes the insurer to rely upon these statements in assessing coverage and underwriting risk.

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