Insurance Electrical Exclusion Form

INSURANCE ELECTRICAL EXCLUSION FORM

Applicant / Insured Information

Insurer Name:   Policy Number:

Date of Birth:   Contact Phone:   Email:

Policy Details

Property    Commercial / Business    Other:

Policy Period From:   To:

Electrical Exclusion Terms

Pursuant to the authority of the Insurer under the referenced policy, the parties hereby agree that the policy shall be amended by adding the following Electrical Exclusion. The Insurer shall not be liable for direct or indirect loss, damage, cost or expense caused by, resulting from, contributed to by, or consisting of any of the following electrical occurrences: electrical arcing, short circuit, power surge, spike, brownout, blackout, voltage fluctuation, electrical overload, mechanical or electrical breakdown, failure or malfunction of electrical equipment, wiring, motors, transformers, control devices, electronic components, integrated circuits, or any component thereof (collectively, "Electrical Event"). This exclusion applies regardless of whether the Electrical Event causes or contributes to fire, smoke, water, or other consequential or secondary damage, except as expressly provided in the Exceptions section below.

The Insured acknowledges and agrees that unless an exception is expressly elected and counter-signed by an authorized representative of the Insurer, any claim arising out of an Electrical Event is excluded from coverage.

Effective Date of This Exclusion:

Exceptions (Optional Endorsements)

The following exceptions to the Electrical Exclusion may be attached only if specifically indicated and countersigned by an authorized insurer representative. Check each exception to apply it to the policy.

Exception A — Fire resulting directly from an electrical malfunction is covered subject to a sublimit and the conditions below.

Exception B — Replacement cost coverage for specific electronic equipment subject to prior approval and specified sublimit.

Conditions, Representations and Warranties

The Insured represents and warrants that all electrical systems and equipment insured under the policy are installed in accordance with applicable construction and electrical codes and maintained in a condition reasonably fit for use. The Insured further warrants that surge protection devices, grounding, and safety devices required by code are installed and maintained where reasonably applicable. Failure to maintain required devices or to comply with applicable codes may void any coverage otherwise provided under any exception to this exclusion.

Initial to indicate acknowledgement of the foregoing representation and warranty:

Claims Reporting and Documentation Requirements

In the event of loss or damage that may involve an Electrical Event or related damage, the Insured must:

• Notify the Insurer in writing within 72 hours of discovery;
• Preserve and protect the damaged property until inspected by the Insurer or its representative;
• Obtain a licensed electrician's report identifying ignition point, cause, and condition of wiring;
• Provide original receipts, maintenance records, and any prior repair documentation requested by the Insurer; and
• Permit the Insurer to subrogate against any third party where applicable.

Photographs of damage    Licensed electrician's report    Original receipts and invoices    Maintenance records

Beneficiary Designation (If Applicable)

Beneficiary Name:   Relationship:   Share (%):

Acknowledgement and Certification

I certify that the information provided in this form is true and correct to the best of my knowledge. I understand that this Electrical Exclusion Form, when accepted and signed by an authorized representative of the Insurer, will become an amendment to the policy identified above and will be binding on me and all persons covered by the policy. I acknowledge that I have had the opportunity to review the terms of this exclusion and its exceptions and that I understand the effect of the exclusion on coverage for losses arising from Electrical Events.

Signature indicates acceptance of the terms set forth in this form and authorizes the Insurer to amend the policy accordingly. False statements or material misrepresentations may result in denial of coverage.

Insurer Use Only

Effective Date of Endorsement:

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