Insurance Exposure Checklist

INSURANCE EXPOSURE CHECKLIST

Applicant / Insured Information

Individual    Corporation    LLC    Partnership    Trust    Other (describe below)

Date of Birth or Date of Formation:

Policy Details

Policy Type (check all to be quoted):
General Liability    Commercial Property    Commercial Auto    Workers' Compensation    Professional Liability    Cyber Liability    Umbrella/Excess

Policy Period From: To:

Exposure — Property & Operations

Building Sprinklers: Yes    No      Fire Alarm: Yes    No

Operations / Activities — Select Applicable

Use or storage of hazardous materials
Manufacturing
Retail sales to public
Products / Completed operations exposure
Professional services provided
Use of subcontractors (describe below)
Work at heights / elevated exposures
Food preparation / catering

Auto / Fleet Exposures

Do you own or lease vehicles? Yes    No

Cyber & Data Exposures

Does the organization store or process sensitive personal or payment card data? Yes    No

Use of third-party cloud or managed service providers: Yes No

Claims / Loss History

Any losses or claims in the last 5 years? Yes    No

Contractual / Certificate Requirements

Additional insured required by contract: Yes No

Indemnity / Hold harmless required: Yes No

Beneficiary Information (if applicable)

Documentation Checklist

Please indicate which of the following documents are attached or will be provided:

Completed insurance application
Loss runs for past 5 years
Property / building photos
Equipment or inventory schedule
Lease agreement or proof of ownership
Subcontractor agreements and certificates
Safety / loss control program documentation
Most recent financial statements

Exclusions & Notices

The insurer may apply specific exclusions, limitations, or endorsements based upon the exposures disclosed herein. Typical areas where coverage may be limited or excluded include, but are not limited to: pollution liability arising from the escape of contaminants, loss arising from intentional acts or fraudulent conduct, punitive or exemplary damages where permitted by law, and professional liability for services not specifically declared. Where special hazards exist (for example work at heights, aircraft operations, or operation of heavy machinery), additional underwriting information and endorsements may be required.

Declaration and Certification

By signing below, the insured certifies that the information provided in this Insurance Exposure Checklist is true, correct and complete to the best of the insured's knowledge. The insured understands that this information will be relied upon by the insurer for underwriting and rating purposes and that any material misrepresentation or omission may result in denial of coverage, rescission of the policy, or adjustment of premium. Submission of this checklist does not bind the insurer to provide coverage; coverage is effective only upon issuance of a policy and payment of required premium. The insured agrees to provide additional documentation and allow reasonable inspections where required by the insurer.

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