Insurance Cover Form

INSURANCE COVER FORM

Applicant Name:   Primary Phone:

Applicant / Insured Information

Policy Details

Policy Period From: to   Requested Effective Date:

Coverage Options (Select and specify limits)

Bodily Injury & Property Damage Liability — Limit: $ Medical Payments — Limit: $ Uninsured/Underinsured Motorist — Limit: $ Property Loss / Damage — Limit: $ Business Interruption — Limit: $ Other (specify):

Exclusions and Limitations

Standard exclusions that shall apply to any coverage issued pursuant to this application include, without limitation: intentional acts, fraud, war or military action, nuclear hazard, wear and tear, punitive damages where prohibited, and criminal conduct. Coverage is subject to the terms, conditions and endorsements of the issued policy.

I acknowledge that I have read and understand the standard exclusions above and that additional exclusions may be applied by the insurer.

Beneficiary / Payee Designation

Primary Beneficiary Name:
Relationship: Percentage of proceeds: %

Contingent Beneficiary Name:
Relationship: Percentage of proceeds: %

Prior Losses and Claims

No Yes — If yes, provide details below.

Documentation Checklist

Please attach required documents (check those included):

Copy of government-issued ID Property / Vehicle photos Previous policy declarations Loss reports (if applicable) Additional documentation (list in remarks)

Declaration and Certification

By signing below, the applicant certifies that the information provided in this Insurance Cover Form is true, complete and correct to the best of the applicant's knowledge. The applicant understands that any material misrepresentation or omission may be grounds for denial of coverage or rescission of the policy. The applicant authorizes the insurer and its representatives to obtain and verify any information, including but not limited to prior insurance, claims history, credit reports, and inspection reports, as permitted by law, for underwriting and claims handling purposes.

The applicant acknowledges that coverage is subject to underwriting approval and issuance of a policy document containing the complete terms, conditions, limits and exclusions. No coverage is effective until the insurer has accepted this application and any required premium or deposit has been received, unless a temporary binder is issued in writing by the insurer or its authorized representative.

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