Insurance Declarations Form

INSURANCE DECLARATIONS FORM

1. Insured / Applicant Information

Insured Name:

Date of Birth:    Telephone:    Email:

2. Policy Information

Policy Type (check all that apply):

Property    Liability    Auto    Life    Other (specify below)

Policy Period: From to

3. Coverage Summary and Limits

Select coverages and specify applicable limits and sublimits where required.

Commercial General Liability — Limit: $    Occurrence/Aggregate:

Property — Limit: $    Coinsurance:

Auto Physical Damage — Collision Limit: $ Comprehensive Limit: $

Personal Accident/Medical Payments — Limit: $

4. Exclusions and Endorsements

The policy is issued subject to standard exclusions and any endorsements expressly attached to the policy. The following items represent common exclusions; the Insured acknowledges that these exclusions may apply unless specifically endorsed:

• War, nuclear hazard, and willful acts by the insured;
• Intentional fraud or material misrepresentation;
• Pollution and contamination except where limited coverage is provided by endorsement;
• Wear and tear, gradual deterioration, and maintenance issues.

I acknowledge receipt of the standard exclusions and any policy endorsements attached at inception: Yes

5. Beneficiary Designation (If Applicable)

Primary Beneficiary Name:

Relationship:    Share (%):

Contingent Beneficiary Name:

Relationship:    Share (%):

6. Agent / Broker and Underwriting

7. Declaration and Certification

By signing below, the undersigned declares that the information provided in this Declarations Form is true, complete and provided in good faith. The undersigned understands and agrees that:

• The Insurer will rely upon these statements in issuing the policy and setting the premium;
• Material misrepresentation, omission, or concealment of information may result in denial of claims, cancellation or rescission of coverage, or other legal remedies available to the Insurer;
• This Declarations Form becomes a part of the policy only when incorporated by reference or attached to the policy; endorsements and specific policy language govern coverage;
• The Insured consents to electronic communications regarding policy administration if an electronic contact method is provided above.

I affirm under penalty of perjury that the foregoing statements are true and complete to the best of my knowledge and belief.

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