Insurance Extended Warranty Quote

INSURANCE EXTENDED WARRANTY QUOTE

Applicant / Insured Information

Insured Name:

Date of Birth: Phone: Email:

Product / Equipment Details

Manufacturer: Model: Serial Number:

Purchase Date: Original Purchase Price: $

Policy Details & Premium

Quote Reference Number:

Policy Type: Standard Premium Platinum

Coverage Limit: $ Deductible: $ Term (months):

Policy Period From: To:

Coverage Options (select all that apply)

Parts Replacement
Labor Coverage
On-site Service (subject to service area)
Accidental Damage Protection
Power Surge Protection
Theft Protection (subject to police report)
Transferability to Subsequent Owner

Exclusions & Limitations

The quote provided herein is subject to the following standard exclusions and limitations unless expressly endorsed: losses resulting from wilful misconduct, intentional abuse, pre-existing mechanical or electrical failures known prior to the effective date, consequential or incidental damages (including loss of use), failures caused by unauthorized repair or modification, cosmetic damage that does not affect function, damage from normal wear and tear beyond covered parts, and losses otherwise excluded by statute. Coverage for theft, on-site service, and transferability are subject to additional conditions and documentation requirements.

Applicant acknowledges that this document is a non-binding quote and not a policy. Binding coverage is subject to underwriting acceptance, receipt of premium where applicable, and fulfillment of any inspection or documentation requirements set forth by the insurer.

Acknowledgement of exclusions: I have read and understand the exclusions and limitations described above.

Beneficiary / Payee Information

Beneficiary Name:

Relationship to Insured: Allocation Percentage: %

Optional Add-Ons & Endorsements

Zero Deductible Endorsement
Extended Term Purchase (additional months)
Accidental-only Coverage Rider

Declarations and Certification

The undersigned certifies that the information provided on this quote request is true and complete to the best of their knowledge. The insurer may rescind any subsequent policy or deny coverage if material misrepresentations, omissions, or false statements are discovered. Acceptance of a quote and issuance of a policy are conditioned upon satisfactory underwriting, verification of product condition and ownership, and receipt of any required premium. Any binding coverage will be evidenced by a policy document that will supersede this quote and will set forth terms, conditions, exclusions, and claims procedures.

By signing below, the applicant authorizes the insurer and its agents to obtain information necessary to underwrite and service the warranty, to communicate with the seller or service providers, and to share relevant underwriting information with reinsurers and claim administrators as necessary to effect coverage and claims handling.

Agent / Quoter Information (if applicable)

Agent / Broker Name: Agency Identifier:

Agent Phone: Agent Email:

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