Insurance EPLI & Crime Quote

Insurance EPLI & Crime Quote

Applicant / Insured Information

Insured Name:

Policy Details & Quote Parameters

Requested Effective Date: Requested Expiration Date:

Coverage Options — EPLI

Select EPLI coverages requested:

Coverage Options — Crime / Fidelity

Select Crime coverages requested:

Exposures, Controls & Operations

Background checks performed on hires: Yes No

Prior Acts / Retroactive Date & Exclusions

Prior Acts / Retroactive Date (if required for EPLI coverage):

Standard underwriting exclusions that may apply to any quote include: intentional illegal acts by insured, fraud, bodily injury and property damage, punitive damages where unenforceable by statute, war and nuclear risks, and losses arising from transactional liabilities. Any specific exclusion endorsements will be stated in the binder or policy documentation for binding. Insurer retains right to amend terms pending receipt of required documentation and audits.

Claims History (Last 5 Years)

Have there been any claims, suits, or incidents that could give rise to a claim? Yes No

Documentation Checklist

The following documents are required to complete underwriting and bind any quoted coverage. Submit copies with this application where available:

Beneficiary / Loss Payee Designation

(If proceeds are to be applied to a loss payee or beneficiary, identify below)

Declarations, Certification & Quote Conditions

The undersigned certifies that the information contained in this quote request is true, complete and presented in good faith. The information provided will form the basis of any quotation or coverage offered. The quote provided by the insurer is an indication of terms and premium only and does not bind coverage. Coverage is effective only upon issuance of a binder or policy documentation and receipt of any required premium deposit. The insurer may condition binding on receipt and review of required documentation, inspection and completion of any underwriting inquiries. Premiums are subject to audit and adjustment based on final exposures.

The insured authorizes the release of loss history, claim information and other underwriting information by any prior insurer, broker or third party as necessary for underwriting and binding. Any material misrepresentation or omission may be grounds to void coverage in accordance with policy terms.

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