Can I use an electronic signature?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure intent, consent, attribution and retention are documented; consumer-facing financial or health disclosures may require ESIGN consumer consent procedures.

Is notarization required?

Typically the Insurance DIC Application does not require notarization unless the carrier or state law specifically demands it. Confirm with the insurer and state notary rules before obtaining notarization.

Can the form be notarized remotely?

Remote online notarization (RON) is permitted in many states but rules vary. Verify the state notary commission’s RON status and technical requirements before using remote notary services.

What if I make a mistake after signing?

Minor errors may be corrected by executing an amendment or affidavit; material misrepresentations should be disclosed immediately to the insurer. Corrections must follow insurer procedures to avoid coverage disputes.

How to revoke or withdraw an application?

Withdrawal should be communicated in writing to the underwriter or broker. If a signature created a binding offer, consult counsel and the carrier’s binding rules for next steps.

Is PHI allowed on the form?

If the application includes protected health information, HIPAA controls apply and a BAA may be required. Limit PHI to what is necessary and follow HIPAA retention rules (45 CFR §164.530(j)).

Electronic Signature
Templates
Insurance
Insurance DIC Application

Insurance DIC Application

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE DIC APPLICATION

Applicant Name: Entity Type: Individual Corporation LLC Partnership Trust Other

Mailing Address Property Location (if different)

Contact Person

Phone

Email

Date of Birth / Formation Date

Tax ID / EIN

Policy Details

Requested Policy: DIC (All-Risk) DIC including Flood DIC including Earthquake DIC (Limited Perils)

Coverage Limit

Deductible

Annual Premium (Estimate)

Policy Period From

Policy Period To

Coverage Options and Limits

Select coverages to be included under the DIC policy. For each selected coverage, provide the desired limit where indicated.

Building Coverage — Limit:

Business Personal Property / Contents — Limit:

Business Interruption / Extra Expense — Limit: Period:

Equipment Breakdown — Limit:

Ordinance or Law Coverage — Limit:

Contingent Business Interruption — Limit:

Standard Exclusions and Limitations

The DIC policy shall not provide coverage for loss or damage excluded by the underlying primary policy, nor for perils expressly excluded by the DIC policy including, but not limited to, nuclear hazard, war and military action, intentional acts by the insured, wear and tear, gradual deterioration, inherent vice, unexplained disappearance, and losses arising from governmental seizure. The insurer may also exclude losses caused by flood or earthquake unless specifically endorsed.

Applicant hereby acknowledges receipt of and assent to the exclusions and limitations set forth in this application and authorizes underwriting to rely upon the disclosures herein. Applicant understands that coverage will be subject to the policy terms, conditions, endorsements, limits and deductibles agreed to at binding.

I have read and accept the exclusions and limitations as stated above.

Prior Loss and Claims History (Last 5 Years)

Provide all losses attributable to the insured locations. Attach additional pages if necessary.

Claim 1 — Date of Loss Claim 1 — Type and Amount Claim 1 — Description Claim 2 — Date of Loss Claim 2 — Type and Amount Claim 2 — Description

Risk Control and Protective Measures

Indicate existing loss control measures at the insured premises.

Automatic Sprinkler System — Last inspection:

Fire Alarm / Central Station — Monitoring Company:

Security Alarm / Patrol — Details:

Seismic Retrofit Completed — Date:

Attachments and Documentation Checklist

Please indicate which documents are attached to this application.

Primary Policy Declarations

Loss Runs (last 5 years)

Property Valuation / Appraisal

Inspection Reports / Certificates

Building Plans / Construction Documents

Beneficiary / Payee Designation

Specify the payee for policy proceeds in the event of loss. If none, indicate "NA".

Beneficiary / Payee Name

Relationship to Insured

Percentage of Proceeds

Certification and Authorization

By signing below, the applicant certifies that the information contained in this application is true, complete and correct to the best of the applicant's knowledge and belief. Applicant acknowledges that material misrepresentation or omission may be grounds for denial of coverage or rescission of the policy. Applicant authorizes the insurer to obtain loss history, underwriting information and relevant reports from prior insurers, claims services, and other legitimate sources as part of underwriting and claims handling.

Applicant further acknowledges that any binding of coverage is subject to the insurer's review and acceptance of underwriting information, payment of premium, and execution of a formal policy document incorporating the terms, conditions, limits and exclusions agreed upon.

Printed Name:

Signature:

Date:

Title / Capacity (if signing on behalf of entity):

Phone for signature verification:

What the Insurance DIC Application Is and when it’s used

An Insurance DIC Application is the form completed by an insured or broker to request Difference-in-Conditions (DIC) coverage or a related policy endorsement that fills gaps between primary policies and broader coverage. It collects policyholder identity, risk descriptions, prior loss history, existing coverage limits and exclusions, and underwriting disclosures. Underwriters use the application to assess exposure, price coverage, and set policy terms. The form is typically submitted to the insurer or managing general agent and may require supporting documents such as property schedules, loss runs, and proof of current insurance.

Why a clear, complete Insurance DIC Application matters

A properly completed Insurance DIC Application reduces underwriting delays, minimizes coverage disputes, and helps ensure accurate premium calculation and contract terms.

Who typically completes and reviews this application

Primary users include insureds, brokers, risk managers, and underwriting teams who exchange coverage details and documentation.

Insurance brokers and agents who gather data and submit on behalf of clients
Risk managers for commercial policyholders verifying exposure and limits
Underwriters and claims teams evaluating acceptance and pricing

Secondary reviewers may include legal counsel, loss control consultants, and third‑party administrators depending on the transaction complexity.

Core elements found in a professional Insurance DIC Application

A well-structured application organizes identity data, risk description, coverage history, endorsements requested, and declarations needed for underwriting and claims evaluation.

Applicant

Full legal name, entity type, EIN or SSN, contact details and mailing address for policy and billing communications.

Risk Details

Precise location descriptions, property values, operations summary, occupancy, and loss exposures that materially affect underwriting.

Coverage Sought

Requested limits, deductibles, effective dates, and any gap coverage specifics that define the DIC scope relative to primary policies.

Prior Insurance

Names of current carriers, policy numbers, limits, effective dates, and any recent cancellations or nonrenewals.

Loss History

Loss runs for the past five to seven years showing claim amounts, dates, reserves and status for underwriting review.

Declarations

Signatures, attestations of truthfulness, and consent to share information for underwriting and claims handling.

Step-by-step: completing and submitting the application

Follow these steps to prepare a complete submission and reduce follow-up requests.

01

1. Gather documents: Collect loss runs, current policies and valuation schedules.
02

2. Complete form: Fill every required field; use MM/DD/YYYY for dates.
03

3. Attach evidence: Upload supporting documents in PDF or DOCX format.
04

4. Submit to carrier: Send to underwriting contact or MGA via agreed channel.

How application processing typically flows

A standard processing path moves from submission through underwriting to binding or requests for clarification.

Submission: Insured or broker uploads completed application and attachments.
Underwriting Review: Underwriter assesses exposures, requests clarifications if needed.
Pricing & Terms: Carrier issues proposed premium, deductibles, and exclusions.
Binding: Policy is bound after required signatures and payment.

Typical digital workflow settings for online completion

Configure these settings to streamline eSubmission and ensure consistent routing.

Field	Configuration
Signature Field	Required — signer authentication via email or SMS code
Attachment Field	Required — PDF preferred; max file size per carrier
Conditional Questions	Display follow-ups when exposures exceed specified thresholds
Routing	Send to broker first, then underwriting queue

Delivery channels and technical compatibility for electronic submission

Use secure channels and standard file types to avoid processing delays and ensure records are auditable.

Formats: PDF, DOCX, XLSX supported
Integrations: Salesforce, NetSuite, Google Workspace
Security: TLS in transit, AES-256 at rest

Common timing expectations for underwriting and binding

Timelines vary by carrier and complexity; below are typical expectations to plan around.

Initial Acknowledgement:

Carrier acknowledges receipt within 1–3 business days

Underwriting Review:

Standard review completes in 5–15 business days

Additional Information Requests:

Expect follow-up within 3–7 business days after request

Policy Binding:

Binding occurs after signature and payment, often within 1–5 days

Effective Date Control:

Effective dates set by insurer and may require prior coverage proof

Key milestones from submission to policy in force

A concise milestone view helps coordinate document collection, approvals, and payment for timely binding.

01

Document Collection

Complete all attachments and loss runs before submission.

02

Underwriting Decision

Underwriter issues acceptance, conditional terms, or declination.

03

Policy Preparation

Carrier drafts policy, endorsements, and declarations page.

04

Finalization

Signatures and payment finalize the contract and activate coverage.

Frequent mistakes that slow DIC application processing

Incomplete loss runs omitting claim details and reserves cause underwriting delays and follow-up requests.
Inconsistent party names between application and prior policies trigger verification and can delay binding.
Missing property valuations or schedules lead underwriters to request inspections or independent appraisals.
Failure to disclose prior cancellations or material changes can result in rescission or claim denial.

Short risks and consequences for errors or omissions

Coverage Denial: Claims may be denied for material misrepresentation.

Rescission: Policy can be rescinded for false statements.

Premium Adjustment: Underwriter may increase premiums retroactively.

Delayed Payment: Claim payments may be withheld pending investigation.

Regulatory Risk: Noncompliance can trigger regulators' inquiries.

Contractual Gaps: Gaps may leave exposures uninsured.

eSignature vendor pricing snapshot for document execution

Compare starting prices and core capabilities relevant to Insurance DIC Application workflows; signNow is listed first for parity with other vendors.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about completing and signing the Insurance DIC Application

Practical answers to common questions about eSigning, notarization, corrections, and legal validity for this application.

Need help? Contact support

Can I use an electronic signature?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure intent, consent, attribution and retention are documented; consumer-facing financial or health disclosures may require ESIGN consumer consent procedures.
Is notarization required?
Typically the Insurance DIC Application does not require notarization unless the carrier or state law specifically demands it. Confirm with the insurer and state notary rules before obtaining notarization.
Can the form be notarized remotely?
Remote online notarization (RON) is permitted in many states but rules vary. Verify the state notary commission’s RON status and technical requirements before using remote notary services.
What if I make a mistake after signing?
Minor errors may be corrected by executing an amendment or affidavit; material misrepresentations should be disclosed immediately to the insurer. Corrections must follow insurer procedures to avoid coverage disputes.
How to revoke or withdraw an application?
Withdrawal should be communicated in writing to the underwriter or broker. If a signature created a binding offer, consult counsel and the carrier’s binding rules for next steps.
Is PHI allowed on the form?
If the application includes protected health information, HIPAA controls apply and a BAA may be required. Limit PHI to what is necessary and follow HIPAA retention rules (45 CFR §164.530(j)).

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