Insurance Cover Sheet

INSURANCE COVER SHEET

Insured / Applicant Information

Insured Name:

Date of Birth:    Tax ID / SSN (last 4):

Policy / Coverage Summary

Policy Number:    Policy Type:

Policy Period From:   To:

Coverage Sections (select all that apply)

General Liability
Property / Building
Commercial Auto
Professional Liability / E&O
Workers' Compensation
Cyber Liability
Other (specify)

Beneficiary Designation

Primary Beneficiary Name:

Relationship:   Share %:

Exclusions and Acknowledgements

The insurance coverage specifically excludes losses arising from the following unless endorsed: intentional acts, known and undisclosed prior losses, punitive damages where prohibited, wear and tear, and fraud. The insured acknowledges that the insuring agreements, conditions and exclusions contained in the policy form control the rights and obligations of the parties.

I acknowledge that I have read and understand the exclusions stated above and that the policy shall be subject to its full terms and conditions.

Claims & Prior Loss Information

Any known losses or claims in the last five years must be disclosed. Failure to disclose material claims may result in denial of coverage or rescission.

Attachments / Documentation Checklist

Please indicate which documents accompany this cover sheet:

Completed Application
Endorsements / Riders
Prior Policies
Loss Runs / Claims History
Photographs / Diagrams
Other (describe below)

Underwriting / Broker Notes

Declaration and Authorization

I hereby declare that the information provided on this Insurance Cover Sheet is true and complete to the best of my knowledge. I understand that any material misrepresentation, omission, or failure to disclose relevant facts may constitute grounds for denial of claims, cancellation of coverage, or rescission of the policy ab initio. I authorize the insurer and its representatives to make inquiries and obtain such information as is necessary to underwrite and service the policy, including but not limited to verifying prior insurance, claims history and relevant loss information. I understand premiums, endorsements and the final policy terms are governed by the issued policy and endorsements.

By signing below I certify that I have authority to bind the named insured and that I have read and understand the statements contained in this document.

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