Establishing secure connection…Loading editor…Preparing document…

Insurance Excess Ategrity Form

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

Insurance Excess Ategrity Form

Applicant / Insured Information

Date of Birth:   Tax or Business ID:   Contact Phone:

Policy and Coverage Details

Primary Policy Number:   Primary Policy Limits:

Existing Excess or Umbrella Carrier (if any):

Requested Deductible:   Estimated Annual Premium:

Proposed Policy Period From:   To:

Coverage Selection

Please indicate which coverage the excess policy is intended to follow (check all that apply):

Umbrella / Excess Endorsements Required:

Exclusions, Limitations and Acknowledgements

The applicant acknowledges that the proposed excess policy will contain customary exclusions, including but not limited to asbestos, pollution arising from long-term discharge, intentional acts, and criminal acts. Applicant must disclose any known exposures that may be the subject of exclusion below.

Claims / Loss History

Number of claims or suits in the past five (5) years:   Total incurred and paid:

Required Attachments Checklist

The following items must accompany this application. Check those included and identify any pending items.

Beneficiary / Payee Designation (If Applicable)

Beneficiary Name:   Relationship:

Beneficiary Percentage:

Declarations, Representations and Authorization

By signing below, the Applicant affirms that all information provided in this Insurance Excess Ategrity Form and any attached documentation is true, complete and correct to the best of the Applicant's knowledge. The Applicant understands that the carrier will rely upon these statements in determining eligibility and premium and that material misrepresentation or omission may result in rescission, voidance of coverage, or denial of claims.

The Applicant authorizes the insurer and its representatives to obtain claim and underwriting information and to disclose information to reinsurers and third parties as required for underwriting, placement and administration of any policy issued. The Applicant agrees to cooperate with reasonable requests for documentation and to provide notice of any material change in risk or exposures prior to inception and during the policy period.

Subrogation: The Applicant acknowledges that, unless otherwise agreed in writing, the excess policy will contain standard subrogation and recovery provisions. The Applicant will not, without the insurer's written consent, waive its rights of recovery against any third party where recovery would reduce insurer's loss.

Premium Adjustment and Audit: Any premium quoted is subject to adjustment based on exposure changes, underwriting review of submitted documentation and audit of actual exposures. The Applicant agrees to pay any additional premium determined in accordance with policy terms.

Certification

I certify, under penalty of perjury and to the best of my knowledge, that the foregoing statements and representations are true and complete. I understand that submission of this form does not bind coverage; coverage will be effective only upon issuance of an excess policy and receipt of any required premium.

I further certify that I have authority to execute this form on behalf of the Applicant and that this form has been completed after due inquiry.

Applicant Name:

Signature:

Date:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Insurance Excess Ategrity Form Is

The Insurance Excess Ategrity Form is a standardized document used to report, allocate, and accept liability or coverage above a primary policy layer. It captures insured identity, underlying policy details, excess limit requested, loss description, and claims attachments so excess carriers and brokers can determine coverage triggers. The form reconciles primary insurer payments, documents exhaustion of underlying limits where applicable, and creates a clear record for excess placement or recovery. It is commonly used by brokers, claims teams, and excess insurers to establish entitlement and begin excess claim handling.

Why this Form Matters for Excess Coverage

A complete Insurance Excess Ategrity Form speeds excess coverage decisions and reduces disputes by documenting exhaustion, policy layering, and allocation. Proper execution supports legal enforceability under the ESIGN Act (15 U.S.C. ch. 96) and most state UETA frameworks when signed electronically, and it clarifies responsibilities between primary and excess carriers.

Why this Form Matters for Excess Coverage

Who Typically Prepares and Signs This Form

Clear role assignments reduce rework: brokers collect documentation, primary carriers confirm payments, and excess carriers authorize coverage or request supplements.

  • Insurance brokers and placing agents who assemble policy stacks and submit excess requests.
  • Claims adjusters from primary insurers documenting payments and limit exhaustion.
  • Excess carriers and underwriting teams that evaluate attachment points and indemnity exposure.

Typical Signatories and Their Roles

Claims Manager

The Claims Manager signs to confirm primary payments, provide loss reserves, and attest to allocation. Their signature establishes the factual basis for excess attachment and supports subsequent subrogation or recovery actions.

Broker/Agent

The Broker signs to certify policy placement details, attach required endorsements and notices, and confirm that the excess carrier received accurate underlying documentation, enabling underwriting and coverage determination.

Essential Data Elements on the Form

Insured Name: Legal entity name
Primary Policy: Carrier and policy number
Excess Layer: Attachment point and limit
Loss Details: Date, location, description
Payments Made: Primary insurer payment totals
Supporting Attachments: Reserve notes, invoices, photos

Consequences of Incorrect or Incomplete Forms

Claim Denial: Missing exhaustion evidence may lead to excess denial
Delayed Payment: Incomplete attachments slow underwriting decisions
Coverage Dispute: Ambiguous allocation can trigger litigated disputes
Regulatory Scrutiny: Inaccurate filings can prompt regulator inquiries
Subrogation Loss: Poor documentation reduces recovery prospects
Reputational Harm: Repeated errors damage broker-carrier trust

Common Preparation Errors to Avoid

  • Submitting the form without the underlying primary insurer payment confirmation, which prevents proving exhaustion of limits and stalls excess evaluation.
  • Using inconsistent insured names or policy numbers between attachments and the form, creating identity mismatches that require time-consuming corrections.
  • Failing to include a clear timeline of payments and reserves, which makes allocation questions harder to resolve and increases the risk of coverage disputes.
  • Uploading low-quality or incomplete supporting documents (invoices, photos, police reports), forcing follow-up requests and delaying claim resolution.

Real-World Examples of Use

These brief examples show how the Insurance Excess Ategrity Form supports different workflows and outcomes.

Broker Submission

A broker assembled primary payment confirmations and signed the excess form to request coverage

  • Broker supplied full invoices and reserve notes
  • The excess carrier accepted the submission and issued a coverage determination within ten business days, avoiding litigation and enabling prompt claim payment.

Claims Verification

A primary carrier completed the payment section and attached a sworn loss statement

  • Primary adjuster certified reserve amounts
  • Excess underwriting used the certified record to allocate exposure and approved excess indemnity coverage after a targeted document review.

How to Complete the Form — Step by Step

Follow these sequential steps to prepare an accurate Insurance Excess Ategrity Form and minimize follow-up requests.

  • 01
    Gather Documents: Collect primary policy, proof of payment, invoices, and photos.
  • 02
    Describe the Loss: Provide a concise narrative including dates and locations.
  • 03
    Confirm Payments: Primary insurer documents must show payment amounts and dates.
  • 04
    Sign and Attach: Authorized representatives sign and attach required exhibits.

Where the Form Goes and Who Reviews It

Routing varies by placement but typically involves coordinated submissions to brokers, primary carriers, and excess underwriters.

  • Broker Upload: Broker uploads completed form and supporting docs to claims portal.
  • Primary Confirmation: Primary carrier reviews and confirms payment and exhaustion.
  • Excess Underwriting: Excess carrier assesses attachment point and exposure.
  • Claims Resolution: If accepted, excess carrier issues coverage instructions.

Core Sections of a Professional Insurance Excess Ategrity Form

A well-designed form clearly separates identity, policy facts, loss information, allocation, attachments, and attestations to support fast underwriting and claims decisions.

Insured Details

Full legal name, entity type, mailing and service address, and contact for loss correspondence to prevent identity mismatches during underwriting.

Underlying Policy

Primary carrier name, policy number, policy period, limits, and deductible to show the layer structure and link to exhaustion evidence.

Loss Description

Concise factual timeline, cause, location, and key witnesses to enable quick factual assessment by claims and underwriting teams.

Payments & Reserves

Itemized payments, reserves, and dates from the primary insurer to document exhaustion and calculate excess attachment points clearly.

Attachments List

Index of supporting documents such as paid invoices, proof of payment, photos, police reports, and expert reports for efficient review.

Signatures & Attestation

Signature blocks for authorized representatives with date, title, and attestation language confirming accuracy of the submitted materials.

Supporting Documents to Include with the Form

Attach high-quality, clearly labeled documents that corroborate the primary carrier payments, damages, and any relevant investigations.

Payment Records

Paid invoices, clearinghouse remittances, or bank transfer confirmations that demonstrate amounts applied to the loss and date of payment for exhaustion verification.

Adjuster Reports

Primary insurer adjuster notes and reserve memos providing the factual basis for payment decisions and a summary of claimed damages and liabilities.

Photographs & Estimates

Clear photos, repair estimates, and vendor invoices that substantiate the scope and cost of repairs or replacement related to the loss.

Legal or Police Records

Police reports, litigation pleadings, or legal notices that affect liability determinations or coverage reservations and must be factored into allocation.

Tips for Accurate and Efficient Completion

Adopt consistent formatting and quality checks to reduce processing time and avoid common rejections.

Standardized Templates
Use a single, validated form template across your organization and require typed entries where possible to reduce legibility errors and speed automated data extraction.
Clear Attachment Index
Number and label each attachment referenced on the form so reviewers can quickly cross-check documents without opening every file.
Authorized Signers
Maintain a current list of authorized signatories and require title and date with each signature to prevent invalidation when parties change.
Quality Control
Require a second reviewer to confirm policy numbers, payment amounts, and dates before submission to limit follow-up and dispute risk.

Key Processing Milestones for a Submission

Track these milestones to set expectations and monitor progress from submission through excess decision.

01

Document Assembly

Prepare and attach required exhibits before submission to avoid immediate requests for additional information.

02

Primary Confirmation

Obtain primary insurer written confirmation of payments and reserves, which supports excess attachment.

03

Underwriting Review

Excess underwriting reviews materials and requests clarifications or additional exhibits if necessary.

04

Coverage Determination

Excess carrier issues acceptance, reservation, or denial and communicates any required next steps.

Typical Timing and Deadlines to Expect

While times vary by carrier, these are common targets for processing stages and submission windows.

Initial Submission Window:

Submit within 30 days of primary payment to maintain smooth handling.

Primary Confirmation Timeframe:

Expect primary confirmation requests to be answered within 7–14 business days.

Underwriting Review Goal:

Target 10–20 business days for initial excess underwriting assessment with complete materials.

Additional Documentation Requests:

Provide requested supplements within 5–10 business days to avoid re-prioritization.

Final Decision Window:

Aim for a final coverage response within 30–45 business days for routine matters.

How to Customize the Form for Electronic Workflows

Configure fields and routing to match organizational roles and reduce manual handoffs during electronic submission.

Field Configuration
Signature Blocks Require role-based signatures and date fields for each party
Conditional Fields Show reserve details only when payment fields indicate partial settlement
Attachment Types Define required attachment types and make upload mandatory
Routing Order Send to broker, then primary carrier, then excess underwriter

Digital Submission and Integration Considerations

Ensure the platform retains an auditable certificate of completion and stores records with encryption at rest and in transit.

  • Integrations: Connectors for systems like Salesforce, NetSuite, Microsoft 365, and Box streamline document transfer
  • File Formats: Accept PDF and DOCX; maintain original file fidelity for evidentiary uses
  • Authentication: Support email, SMS codes, or stronger methods for signer attribution

eSignature Pricing and Feature Snapshot for Form Workflows

Comparison of representative vendors and key plan attributes relevant to high-volume insurance form signing and compliance workflows.

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 Yes, 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about signature validity, notarization, submission issues, and revising the Insurance Excess Ategrity Form.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.