Insurance Final PFA

INSURANCE FINAL PFA

This Insurance Final PFA (Final Policy and Fee Acknowledgement) confirms final acceptance of the terms, conditions, coverages and final premium for the policy described below. Insurer Name: Policy Number: Insured Name:

Applicant / Insured Information

Date of Birth: Phone: Email:

Policy Details

Property   Liability   Auto   Life & Health   Cyber Liability

Policy Period Commencement: Expiration: Issuance Date:

Coverage Sections

Select coverages included in final policy (check all that apply):

Property Damage    Bodily Injury    Medical Payments    Uninsured/Underinsured Motorist

Comprehensive    Collision    Cyber Liability    Business Interruption

Exclusions

The following standard exclusions apply unless expressly added by endorsement: intentional acts, fraudulent acts, war and acts of foreign enemies, nuclear hazard, normal wear and tear or gradual deterioration, pollution and contamination unless specifically endorsed, professional liability not otherwise covered, and governmental seizure. Any additional exclusions negotiated are set forth below.

I acknowledge that I have received and reviewed the policy exclusions and that these exclusions form a contractual part of the policy:

Beneficiary Designation (if applicable)

Beneficiary 1

Beneficiary 2

Beneficiary 3

Claims Disclosure

Have any claims, losses or notices of potential claims been made against the applicant in the past five years? Yes No

Documentation Checklist (final submission)

The undersigned shall submit the following as part of final policy issuance (check all attached):

Copy of government-issued ID   Loss or property photos (if applicable)   Police report (if applicable)   Prior policy declarations (if applicable)

Declaration and Certification

By signing below, the applicant certifies under penalty of perjury that all statements and representations contained in this Insurance Final PFA and any attachments are true, complete and correct to the best of the applicant's knowledge. The applicant acknowledges receipt of the final policy terms, coverage limits, deductibles and premium and agrees to the payment and policy conditions specified herein. The applicant understands that any material misrepresentation or omission may result in policy rescission, denial of coverage, or adjustment of coverage effective date and premium. The applicant also consents to the insurer's use of information provided for underwriting and claims adjudication, and consents to reasonable verification of submitted documentation.

Cancellation and premium adjustment provisions as set forth in the policy will apply. The applicant acknowledges that acceptance of this Final PFA by the insurer constitutes issuance of the final policy subject to payment and fulfillment of any conditions precedent listed above or in accompanying endorsements.

Fraud Warning: Where applicable, any person who knowingly and with intent to defraud the insurer submits an application or files a claim containing false, incomplete or misleading information may be subject to civil and criminal penalties under applicable law.

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