Insurance DIC Acknowledgment Form

INSURANCE DIC ACKNOWLEDGMENT FORM

This Insurance Difference‑in‑Conditions (DIC) Acknowledgment Form documents the insured's understanding of the DIC product and its relationship to underlying/primary insurance. The undersigned Applicant affirms the accuracy of the information below and acknowledges the specific coverages, exclusions, duties, and conditions described in this form.

Applicant / Insured Information

Insured Name:

Contact Phone:    Email:

Date of Birth / Organization Date:

Policy and Coverage Details

Primary Policy Number:

DIC Policy Number:

Policy Period (Effective):   to  

Coverage Limit (Per Loss): $    Deductible: $

Premium (DIC): $

Coverage Selections (check all that apply)

All‑Risk DIC (provides coverage for causes of loss not covered by the primary policy, subject to DIC policy terms)

Property Damage

Business Interruption / Extra Expense

Ordinance or Law / Code Upgrade

Debris Removal / Demolition Costs

Pollution Remediation (if endorsed)

Flood (only if specifically endorsed)

Earthquake (only if specifically endorsed)

Exclusions (Representative; see DIC policy for complete exclusions)

The DIC policy excludes, without limitation, loss or expense arising directly or indirectly from: nuclear hazard; war, hostilities or insurrection; intentional acts by the insured; wear and tear, deterioration, latent defects or mechanical breakdown; fraudulent or dishonest acts; and any loss or peril already fully insured by the primary policy where no difference exists. Pollution, contamination, and consequential loss may be excluded unless specifically endorsed.

I acknowledge that I have read and understand the exclusions listed above and in the DIC policy form. Initials:

Loss Payee / Beneficiary

Beneficiary Name:

Relationship to Insured:    Percentage of Proceeds:

Conditions, Duties, and Certification

1. Applicability: The DIC policy applies only to the extent that there is a difference between the terms, limits, or coverages of the DIC policy and those afforded by the underlying primary policy(ies). Where the primary policy provides coverage, the DIC policy will not duplicate the primary insurer's obligations except to the extent expressly provided in the DIC endorsement.

2. Notice and Cooperation: In the event of a loss which may give rise to a claim under the DIC policy, the insured must promptly notify both the primary insurer and the DIC insurer, provide full cooperation, tender proof of loss and documentation requested, and permit examination under oath. Failure to comply may impair coverage.

3. Subrogation: The insured agrees that, to the extent of payment under the DIC policy, the DIC insurer shall be subrogated to all rights of recovery against third parties. The insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights.

4. Premium and Cancellation: Premiums for DIC coverage are payable as set forth in the DIC policy. The DIC insurer may cancel or nonrenew consistent with the terms of the DIC policy and applicable law. Cancellation of the primary policy does not automatically cancel DIC coverage unless the DIC policy so provides.

5. No Amendment: This acknowledgment does not amend, alter, or extend the terms, limits, conditions, exclusions or endorsements of the DIC policy itself. The insured acknowledges responsibility to read the DIC policy and any endorsements for complete terms.

By signing below I certify, under penalty of perjury and to the best of my knowledge, that the information provided in this acknowledgment is true and complete, that I have read and understand the DIC coverage description, limitations and exclusions set forth above, and that I am authorized to request the DIC coverage identified on this form.

I understand that this form is an acknowledgement only and does not bind the insurer to issue or renew coverage beyond the terms of the DIC policy and its endorsements. I authorize the release of information necessary to effect coverage and to process claims.

Acknowledgement of Exclusions and Duties: Applicant acknowledges and accepts the exclusions, duties and conditions described above.

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