Insurance GL & BPP Application Form

INSURANCE GL & BPP APPLICATION FORM

Applicant / Insured Information

Entity Type: Individual Corporation LLC Partnership Other

Contact Person: Phone: Email:

Owner / Principal Date of Birth:

Business Operations & Financials

Years in Business: Number of Employees:

Policy Details Requested

Requested Effective Date: Policy Term (months):

General Liability Coverage Options

Coverage Form: Occurrence Claims-Made (Check only one)

Additional GL Coverages (select all that apply): Products — Completed Operations Personal & Advertising Injury Fire Damage Legal Liability Medical Payments

Business Personal Property (BPP) Coverage

Coverage Basis: Scheduled by location Blanket limit (total)

Valuation Method: Replacement Cost Actual Cash Value Scheduled items by value

Property Locations (List each location to be insured)

Occupancy: Year Built: Property Limit:

Sprinklered: Yes Unoccupied

Occupancy: Year Built: Property Limit:

Sprinklered: Yes Unoccupied

Exclusions and Optional Coverages

The insurer’s standard policy form contains customary exclusions including but not limited to nuclear hazard, war, intentional acts, pollution (unless specifically endorsed), and wear and tear. Applicant requests consideration of the following optional coverages (select those required):

Prior Insurance & Loss History

Prior Policy Period From: To: Premium Paid:

Has the applicant had any losses, claims, or incidents in the past five (5) years that would be covered under the requested policies? Yes No

Beneficiary / Loss Payee Information

Documentation Checklist

Declarations and Certifications

The undersigned certifies that the information provided in this application is true, complete and accurate to the best of their knowledge. The applicant understands and agrees that:

1. Coverage will be bound and policy issued subject to underwriting review and acceptance by the insurer.
2. Any material misrepresentation, omission or concealment may be grounds for denial of coverage or rescission of the policy, and may affect the right to recover under the policy.
3. The insurer and its representatives are authorized to obtain and share underwriting, claims and loss history information, and to inspect the premises and records at reasonable times.
4. Coverage under a claims-made form may require purchase of supplemental coverage (such as extended reporting period) to protect claims arising after policy termination; selection is applicant’s responsibility.

Fraud Warning: Where permitted by law, any person who knowingly presents false information or conceals a material fact with intent to defraud may be guilty of insurance fraud and subject to civil or criminal penalties.

Applicant Printed Name:

Title / Position: Company:

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