Insurance Coverage Supplement Application

INSURANCE COVERAGE SUPPLEMENT APPLICATION

Applicant Name:

Applicant / Insured Information

Date of Birth:    Telephone:    Email:

Policy Details

Insurer:    Policy Number:

Policy Type:   Homeowners   Auto   Commercial   Liability   Other:

Policy Period From:    To:    Requested Effective Date of Supplement:

Supplemental Coverage Options

Select the coverages you request to add or modify. Selection is subject to underwriting approval and premium adjustment.

Additional Personal Property Coverage — Requested Limit: $

Replacement Cost on Dwelling:

Increased Liability Limit — New Limit: $

Ordinance or Law Coverage (building code upgrade coverage)

Water Backup / Sump Overflow Coverage — Requested Limit: $

Equipment Breakdown Coverage — Limit: $

Business Income / Extra Expense — Monthly Limit: $

Exclusions and Conditions

The following general exclusions apply to any supplemental coverage added by this application unless otherwise expressly stated in an endorsement: loss arising from intentional acts; wear and tear, deterioration or latent defect; war, nuclear hazard, governmental action, and pollution unless specifically endorsed. Supplemental coverages may be subject to separate deductibles, co-insurance provisions and limits of liability as detailed in the policy or endorsement.

Applicant acknowledges that acceptance of this supplement by the insurer is contingent upon underwriting review, physical inspection when required, and payment of any additional premium due. No coverage shall be effective prior to acceptance and issuance of a written endorsement by the insurer, except where a binder or temporary coverage is expressly issued in writing by the insurer or its authorized agent.

Beneficiary Designation (if applicable)

Beneficiary 1 Name:   Relationship:   Share %:

Beneficiary 2 Name:   Relationship:   Share %:

Beneficiary 3 Name:   Relationship:   Share %:

Claims / Loss History Disclosure

Yes     No

Authorization, Declarations and Certification

By signing below, the applicant certifies that all statements and answers contained in this application are true, complete and correct to the best of the applicant's knowledge. Applicant understands that material misrepresentation or omission may result in rescission of coverage, denial of claims, or coverage being voided from inception in accordance with the terms of the policy and applicable law.

Applicant authorizes the insurer or its authorized representative to obtain information necessary to evaluate this application, including loss history, claims records, credit information where permitted, and any other underwriting data. Applicant further authorizes the release of such information by prior insurers, administrators, or other persons to the insurer.

Applicant acknowledges that any additional premium, fees, amended endorsements, or conditions resulting from this supplement will be effective only upon issuance of written endorsement by the insurer. No broker or agent is authorized to alter the terms of the policy except as expressly provided in a written endorsement signed by an authorized representative of the insurer.

Fraud Warning: Any person who knowingly and with intent to defraud an insurer submits an application containing false information or conceals material information may be subject to criminal and civil penalties under applicable law.

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