Insurance Flex Plan

INSURANCE FLEX PLAN

This Insurance Flex Plan application and enrollment form (the "Plan") sets forth the selections, coverages, limits and declarations by the applicant. By signing below the applicant certifies that all information supplied is true, complete and accurate to the best of the applicant's knowledge, and agrees that such information forms the basis for any policy issued under this Plan.

Applicant / Insured Information

Applicant Name:

Date of Birth:   Policy Number (if known):

Policy Details

Policy Type (select all that apply):

Personal Commercial Property Health Life

Other Policy Type (specify):

Premium Payment Frequency: Monthly Quarterly Annual

Policy Period: From to

Coverage Selections

Select coverages and specify limit where applicable:

Liability   Limit:

Collision   Limit:

Comprehensive   Limit:

Personal Injury Protection (PIP)   Limit:

Uninsured/Underinsured Motorist   Limit:

Property Damage   Limit:

Other coverages or specifications:

Exclusions, Limitations and Conditions

The following exclusions, limitations and conditions apply to coverage under this Plan unless otherwise expressly provided in an endorsement attached to the policy:

1. Exclusions: Loss or liability arising from intentional acts, criminal conduct, willful misconduct, nuclear hazard, war, or insurrection is excluded. Losses directly or indirectly resulting from pollution, contamination, mold, or seepage are excluded except to the extent a written endorsement expressly provides coverage.

2. Wear and Maintenance: Coverage does not apply to depreciation, ordinary wear and tear, gradual deterioration, or failure to maintain property in a reasonably safe condition. Repair or replacement for deterioration due to age is excluded.

3. Fraud and Misrepresentation: Material misrepresentation, concealment or fraud by the applicant or any insured, whether prior to or subsequent to loss, shall render coverage voidable in accordance with applicable law. The insurer retains all remedies provided by law for fraud.

4. Subrogation and Recovery: The insurer shall be subrogated to the insured's rights of recovery against third parties. The insured shall cooperate in perfecting the insurer's subrogation rights and will not prejudice such rights by settlement or discharge without insurer consent.

5. Aggregate Limits and Deductibles: Specified aggregate limits and deductibles apply to coverages as set forth in the policy schedule. The insurer's maximum liability for covered losses is the lesser of the actual loss or the applicable limit.

Beneficiary Designation

Designate primary and contingent beneficiaries for policy proceeds where applicable. Percentages should total 100% for primary designation.

Prior Claims and Loss History

Have you had any claims or losses in the past five (5) years? Yes No

Date of Most Recent Loss:   Estimated Damage:

Documentation checklist (select what is available): Photos Police Report Repair Estimates Medical Records

Endorsements and Optional Riders

Optional riders may be added and will be effective only if expressly indicated below and accepted by the insurer.

Identity Theft Coverage   Additional Premium:

Rental Reimbursement   Limit:

Broad Form / Increased Limits   Specify:

Declarations, Authorizations and Certification

By signing this application the applicant represents and warrants that: (a) all statements made herein are true and complete; (b) the applicant will promptly notify the insurer of any material change in risk, occupancy or use; and (c) failure to disclose material facts or any material misstatement may result in rescission of coverage or denial of claims in accordance with applicable law.

The applicant authorizes the insurer and its agents to obtain and verify information relevant to the application, including claims history, underwriting information, and loss records from prior carriers or third parties. The applicant acknowledges that the insurer may exchange relevant underwriting and claim information with other insurers.

Payment of premium is due in accordance with the terms agreed and coverage shall not be effective until the insurer receives any required initial premium, except where applicable law or binder provisions provide otherwise. Cancellation, nonrenewal and reinstatement provisions shall be governed by the policy and applicable law.

Arbitration: Subject to applicable law, disputes arising out of or relating to this policy may be resolved by binding arbitration if both parties agree in writing to arbitrate a particular dispute. Acceptance of arbitration is voluntary and does not limit the insurer's right to pursue remedies permitted by law.

Fraud Warning: Any person who knowingly presents false or fraudulent information in an application for insurance or in the presentation of a claim may be subject to criminal and civil penalties, including denial of benefits and recovery of amounts paid.

Applicant Certification: I certify under penalty of perjury that the information provided on this form is true and correct. I understand that this form, together with any attachments, constitutes the complete application for the insurance referenced herein.

Consent to Electronic Delivery: I consent to receive notices, policy documents and communications electronically where permitted by law.

Additional Remarks / Instructions

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