Insurance Coverage Acknowledgement

INSURANCE COVERAGE ACKNOWLEDGEMENT

Applicant / Insured Information

Policy Details

Policy Type (check all that apply):

Coverages and Limits (Selected)

Indicate specific coverages selected and applicable limit where required.

Exclusions and Noted Limitations

The following summarizes common exclusions and limitations applicable to the coverage acknowledged below. The complete exclusions, conditions, definitions and endorsements are contained in the policy document; this acknowledgement does not amend or expand policy terms.

• Losses arising from intentional or criminal acts by the insured are excluded.
• War, nuclear hazard, and certain governmental actions are excluded unless specifically endorsed.
• Losses excluded by specific endorsements (for example, wear and tear, mechanical breakdown) are not covered.
• Coverages may be limited for business pursuits, professional liability, or specified perils by endorsement.

By initialing below, the insured acknowledges receipt of the exclusions summary and understands that additional exclusions may apply under the full policy terms.

Beneficiary Designation (If Applicable)

Complete this section only where applicable to the policy type (for example, life or certain annuity products). Designation of beneficiary by name, relationship and percentage of benefit.

Acknowledgement and Certification

I, the undersigned Applicant/Insured, declare under penalty of perjury that the foregoing information is true and complete to the best of my knowledge. I acknowledge and agree that:

1. The statements and coverages acknowledged on this form are a record of the coverage selections and limits as understood by me and do not amend, extend, or alter the policy terms, conditions, endorsements, exclusions or limits contained in the actual policy contract issued by the insurer.
2. This acknowledgement is not a binder of coverage unless expressly identified as such in writing by the insurer. Coverage is effective only in accordance with the policy declarations, endorsements and any written binder issued by the insurer.
3. I have read and understand the exclusions and limitations summarized above and recognize that other exclusions and conditions may apply under the full policy wording.
4. Any material misrepresentation, omission or fraudulent statement with respect to information provided to the insurer may result in denial of claims, rescission of the policy, or other remedies permitted by law and the policy contract.
5. I authorize the insurer and its authorized representatives to obtain, verify and disclose information relevant to my application and policy administration, including claims history and other underwriting information, to the extent permitted by law.

By signing below, I acknowledge that I have received a copy of this Insurance Coverage Acknowledgement, that I understand the coverage selections and limitations noted herein, and that I agree to comply with any obligations under the policy including payment of premiums when due.

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