Insurance Excluding Documents

INSURANCE EXCLUDING DOCUMENTS

This Insurance Excluding Documents form documents those specific documents, records, files or classes of documentary material that the Insured elects to exclude from coverage under the policy identified below. By completing and signing this form, the Insured acknowledges the exclusions listed herein shall apply to any claim, adjustment, loss payment, replacement, or other coverage event under the referenced policy as permitted by the policy terms.

Applicant / Insured Information

Date of Birth:   Contact Phone:   Email:

Policy Details

Property Liability Cyber/Data Document Replacement Other

Policy Period: From to

Coverage Options (Document-Related)

The Insured acknowledges the following document-related coverage options under the referenced policy. Check all coverages originally in effect and indicate any adjustments due to exclusions below.

Document replacement, reconstruction and transcription costs Digital media and backups restoration Third-party documents and vendor deliverables Intellectual property and proprietary records

Exclusions — Documents and Records

By checking an exclusion below and/or listing documents in the Exclusion Schedule, the Insured declares that the listed documents or classes of documents are specifically excluded from coverage under the policy for all purposes, including but not limited to loss, replacement, restoration, delay, consequential loss, or business interruption arising from the loss of such documents.

Paper originals and archival records Digital files and electronic records Intellectual property, source code, designs Documents in custody of third parties or vendors Documents identified on the attached Exclusion Schedule No exclusions; all standard coverages retained

Exclusion Schedule — List Documents Being Excluded

Provide a clear description of each document or class of documents excluded. If additional space is required, attach additional pages and reference the attachment number in the Description field.

Premium Adjustment and Effect on Coverage

The Insurer may adjust premium, limits, or other terms of the policy as a result of these exclusions. The Insured understands that by excluding documents or classes of documents, the Insured may reduce available coverage for certain losses and that such exclusions will be reflected in policy endorsements or endorsements to follow.

Beneficiary Information (if applicable)

Representations, Warranties and Certification

The Insured represents and warrants that the information provided on this form is true, complete and correct to the best of the Insured's knowledge. The Insured certifies that the exclusions set forth in this form have been selected knowingly and that the Insured understands the effect of such exclusions on coverage, claims handling, and loss settlement. The Insured further acknowledges that any material misrepresentation may result in rescission or denial of coverage to the extent permitted by the policy and applicable law.

The Insured agrees to indemnify and hold harmless the Insurer for any claim or loss resulting solely from the loss, damage or non-availability of documents that are expressly and validly excluded by this form, except to the extent otherwise provided by the policy or required by law.

Initials to confirm understanding of the exclusion provisions:

Notice

This form, when accepted by the Insurer, shall be incorporated into the referenced policy as an amendment or endorsement. Acceptance by the Insurer will be evidenced by the issuance of an endorsement or written acknowledgment. Until such acceptance, the policy terms remain subject to the original policy language. This document does not by itself bind coverage beyond the Insurer's written acceptance consistent with policy procedures.

Administrative Use / Insurer Acknowledgment

Insurer Acknowledgment Date:

Signature and Certification

The undersigned certifies that the foregoing information is true and that the undersigned is authorized to request and accept the exclusions set forth in this form on behalf of the Insured named above.

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