Insurance Excess DOLI Renewal Application

INSURANCE EXCESS DOLI RENEWAL APPLICATION

Applicant / Insured Information

Policy / Coverage Details

Policy Period From: To:

Coverage Options (Check all that apply)

Workers' Compensation Excess

Employers' Liability Excess

Other Liability Excess (describe below)

Exclusions & Acknowledgments

The proposed excess policy will not provide coverage for liabilities arising from intentional acts, punitive damages where unenforceable by law, bodily injury or property damage arising out of: war or military action; asbestos or silica-related exposures outside the specific coverage grant; pollution except where specifically endorsed; employers' intentional failure to secure payments due to statutory obligations. These exclusions are illustrative and final terms will be dictated by policy language.

Applicant represents that all statements and particulars contained in this application are true, complete, and material to the underwriting decision. Applicant understands that any misrepresentation, omission, or concealment of material facts may result in denial of coverage, rescission of the policy, or voiding of coverage for the affected claim(s).

I acknowledge that I have read and understand the exclusions above and agree that these or other policy exclusions may apply under the renewed excess policy.

Prior Insurance / Loss History

Provide details of losses, claims, or incidents in the last five (5) years. Include Date of Loss, Brief Description, Amount Paid or Reserved, and Current Status.

Have there been any judgments, fines, or regulatory citations related to workplace safety or statutory obligations in the past five years? Yes No

Required Attachments (Check submitted items)

Most recent declarations page(s)

Loss runs for last 5 years

Audited payroll or estimated payroll schedule

Other relevant underwriting documents

Declarations, Authorization and Certification

By signing below, Applicant certifies that the information provided herein is true and complete to the best of Applicant’s knowledge. Applicant understands that this application, including any attachments and representations, will be relied upon by the insurer and its representatives in evaluating the risk for renewal. Applicant agrees to promptly notify the insurer of any material change in exposures prior to policy inception.

Applicant authorizes the insurer and its authorized representatives to obtain loss history, claim, underwriting, and employment records from prior insurers, claims administrators, and relevant governmental agencies. Applicant further authorizes any person or organization to release such information. A photocopy of this authorization shall be as valid as the original.

NOTICE: Fraud Warning — Any person who knowingly presents false information in an insurance application or claim may be guilty of a criminal act and subject to penalties under applicable law.

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