Insurance Excessive Liability Form

INSURANCE EXCESSIVE LIABILITY FORM

1. Insured / Applicant Information

Individual Corporation LLC Partnership Trust Other:

Date of Birth (if individual):    Tax ID / SSN (if required):

2. Policy Details

Coverage Limit (per occurrence): $    Aggregate Limit: $

Deductible / Self-Insured Retention: $    Annual Premium: $

Policy Period: From to

3. Coverage Election and Excess Liability Details

Select coverages to be applied under the Excess Liability treatment (check all that apply):

Excess Liability (over underlying limits)
Umbrella Liability
Employer's Liability
Professional Liability (E&O) subject to policy terms
Product Liability
Other:

Excess Attachment Point (retained limit or underlying limit to be exhausted): $    Limit of Liability Requested: $

4. Exclusions and Limitations

The following exclusions commonly apply to Excess Liability coverage. Indicate any additional exclusions requested or required by the insurer.

War and hostile acts
Intentional acts and willful misconduct
Pollution and contamination (unless endorsed)
Contractual liability beyond indemnity limits
Professional services excluded unless specifically included

5. Prior Losses and Claims History

Provide claims or loss information for the prior five (5) years for any claim in excess of $25,000. Attach separate sheet if necessary.

Date of Loss:    Amount Paid or Reserved: $

6. Beneficiary / Payee Designation (if applicable)

Designate beneficiary or payee for proceeds related to this Excess Liability coverage where applicable (e.g., settlement funds payable to a named loss payee).

7. Declaration, Authorization and Warranty

I, the undersigned Applicant/Insured, declare that the information contained in this Insurance Excessive Liability Form and any attachments is true, complete and accurate to the best of my knowledge. I acknowledge that material misrepresentation, omission or concealment of facts may result in denial of coverage, rescission of the policy, or adjustment of terms and premium.

I authorize the insurer, its representatives and any reinsurers to make any inquiries and obtain any records necessary to evaluate this application, including loss history, financial information and claim files. I agree to cooperate with the insurer in the investigation, settlement and defense of any claim and to provide prompt notice of any occurrence or circumstance which may give rise to a claim.

I understand that acceptance of this application is contingent upon underwriting review and that specific policy terms, conditions, limitations and exclusions will be set forth in the policy and applicable endorsements. No binder or coverage is effective unless issued in writing by the insurer.

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