Insurance Coverage Continuation Form

INSURANCE COVERAGE CONTINUATION FORM

Purpose: Use this form to request continuation of insurance coverage for an existing policy beyond its scheduled expiration, to extend active coverage during pendency of underwriting review, or to continue benefits where permitted by policy provisions. Completion of this form constitutes a written request for continuation and an acknowledgment of the terms and conditions set forth below.

Applicant / Insured Information

Policy Details & Requested Continuation

Policy Type:

Original Policy Effective Date:    Original Policy Expiration Date:

Requested Continuation Period From: To:

Coverage Options / Continuation Scope

Indicate which parts of the original policy are to be continued (check all that apply). Continuation applies only to items checked and is subject to insurer approval and payment of any outstanding premium.

Payment and Billing Instructions

Continuation will become effective only upon receipt of the required premium and any reinstatement fees. Select payment method and indicate payer responsibility.

Exclusions, Conditions, and Limitations

Continued coverage is subject to all policy terms, conditions, endorsements and exclusions in effect under the original policy, except as expressly modified in writing by the insurer. Continuation does not waive any condition precedent to coverage, and the insurer reserves all rights to investigate, adjust, and deny claims in accordance with the policy and applicable law.

Specific limitations that may apply to continuation include, but are not limited to: (a) exclusions for new or changed exposures not previously disclosed; (b) limitations arising from nonpayment of prior premiums; (c) underwriting review that may result in amended terms, additional exclusions, or declination of continuation. Acceptance of this request is at the sole discretion of the insurer.

Beneficiary Designation (If applicable)

Complete this section only if continuation request pertains to life, accidental death, disability, or other benefits requiring beneficiary designation.

Documentation Checklist

Attach required supporting documentation to avoid processing delays. Check each item attached.

Declaration and Certification

I certify that the information provided on this Insurance Coverage Continuation Form is true, accurate, and complete to the best of my knowledge. I understand and agree that:

1. Acceptance of this continuation request is subject to insurer underwriting review and receipt of required premium. The insurer may impose additional terms, endorsements, or limitations as a condition of continuation.

2. Any material misrepresentation, concealment of facts, or omission in this form may be grounds for denial of continuation, rescission of coverage, or adjustment in accordance with the policy and applicable law.

3. I authorize the insurer and its representatives to obtain, use, and disclose information necessary to evaluate this continuation request, including but not limited to policy, claims, and underwriting records. I understand that my signature below constitutes consent to such inquiries where permitted by law.

4. I acknowledge that, unless otherwise agreed in writing, the insurer reserves the right to terminate continuation for nonpayment or upon discovery of undisclosed changes in risk exposure.

Fraud Warning: Any person who knowingly submits false information or omits material facts in connection with an insurance transaction may be guilty of insurance fraud and subject to criminal or civil penalties as provided by law.

By submitting this form, the undersigned represents that they are authorized to request continuation on behalf of the insured and that they have read and accept the declaration above.

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