Insurance Excess Liability Confirmation

INSURANCE EXCESS LIABILITY CONFIRMATION

Insurer Name:    Policy Number:

APPLICANT / INSURED INFORMATION

Date of Birth:    Contact Phone:    Contact Email:

POLICY DETAILS

Policy Type (select applicable): Excess Liability / Umbrella General Liability (included) Commercial Auto (included)

Policy Period: From through

COVERAGE SUMMARY

The Insurer hereby confirms that the policy identified above is written as excess liability coverage that provides limits in excess of the underlying insurance identified below and responds only after the applicable underlying limits have been exhausted. Limit of liability: . Retention/attachment point: .

Coverage Basis: Follows form of underlying policies where endorsed Non-contributory (where applicable)

UNDERLYING INSURANCE (LIST MOST RELEVANT)

Underlying Insurer 1: Policy No.: Limit:

Underlying Insurer 2: Policy No.: Limit:

Underlying Insurer 3: Policy No.: Limit:

EXCLUSIONS AND LIMITATIONS

The excess liability coverage is subject to the full terms, conditions, exclusions, endorsements and limitations contained in the policy. Typical exclusions that may apply include, without limitation: punitive or exemplary damages where prohibited by law, liabilities arising out of intentional acts, liabilities for professional services unless specifically endorsed, nuclear hazards, war and hostile acts, and liability arising from pollution or asbestos except to the extent coverage is expressly extended by endorsement.

Any special endorsements or deviations from standard policy wording that affect attachment, scope of coverage, or the insurer’s obligations are set forth in the endorsements section and additional remarks below.

BENEFICIARY / PAYEE INFORMATION

If any proceeds or recoveries are payable to a designated payee, provide beneficiary details below or indicate Not Applicable. Not Applicable:

DECLARATION AND CERTIFICATION

By signing below, the undersigned Authorized Representative of the Insurer certifies that the information contained in this Insurance Excess Liability Confirmation is true and accurate to the best of their knowledge, that coverage as described is in force for the stated policy period unless otherwise stated herein, and that such coverage shall be governed by the terms, conditions and exclusions of the policy. This confirmation does not amend, extend or alter the coverage afforded by the policy, and any reliance upon this confirmation is subject to the policy terms.

The Insurer further certifies that any notice of cancellation or material change shall be provided in accordance with the notice provisions of the policy and, where required by endorsement, to the certificate or interest holder named hereunder.

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