Insurance Excess Liability Renewal Form

INSURANCE EXCESS LIABILITY RENEWAL FORM

Insured / Applicant Information

Insured Name:

Individual Corporation LLC Partnership Other:

Policy Renewal Details

Current Policy Number:

Coverage Options (select all applicable)

Public / General Liability
Products & Completed Operations
All Operations
Professional Liability (if applicable)
Pollution Liability (specified limits)
Other:

Loss Experience and Claims Information

Have there been any claims, suits, incidents that could give rise to a claim, or losses in the past five (5) years? Yes No

Exclusions, Restrictions and Underwriting Considerations

The insurer may amend terms or decline renewal based on underwriting review, material misstatement, or newly disclosed exposures. The following standard excess exclusions apply unless specifically endorsed: nuclear hazard, intentional acts, war, certain professional exposures, and punitive damages where uninsurable. Additional exclusions or restrictions applicable to this renewal will be set out in the binder or policy endorsement.

Beneficiary / Recovery Contact

Beneficiary Name:

Attachments and Documentation Checklist

Please attach the following documentation where applicable. Check each provided item:

Current underlying policy declarations page(s)
Loss runs for the past five years
Sample contracts / hold harmless agreements
Safety or risk management programs
Audited financial statements (if requested)

Declarations and Authorization

The undersigned declares that the information provided in this renewal form is true, accurate, and complete to the best of their knowledge. Any material misstatement, omission or concealment of fact may be grounds for denial of coverage or rescission of the policy. The undersigned authorizes the insurer and its representatives to make any investigation and inquiry deemed necessary, including obtaining claim and underwriting information from prior insurers, and to disclose underwriting or claim information to reinsurers and affiliate entities where permitted by law.

The applicant agrees that any endorsements, alterations, or special conditions required by the insurer as a condition of renewal will be attached to and become part of the policy if issued. Acceptance of renewal terms by the insurer does not imply waiver of any rights under the existing policy unless explicitly stated in writing.

Initials:

Additional Information / Remarks

Sign Now