Insurance GL Diligent Form

INSURANCE GL DILIGENT FORM

Applicant / Insured Information

Insured Name:

Policy Details

Coverage Options (select all that apply)

Bodily Injury Liability
Property Damage Liability
Products / Completed Operations
Personal & Advertising Injury
Medical Payments
Contractual Liability
Additional Insured Endorsement Requested
Waiver of Subrogation Requested

Exclusions and Acknowledgment

The undersigned acknowledges that standard policy exclusions may apply. The following are common exclusions that affect coverage and require affirmative disclosure or endorsement if coverage is desired.

Pollution / Environmental Liability Exclusion
Professional Services / Errors & Omissions Exclusion
Cyber Liability Exclusion
War and Terrorism Exclusion
Asbestos / Lead Exclusion

I certify that I have reviewed policy exclusions and request coverage endorsements where necessary. I understand that failure to disclose operations, exposures or prior conditions may result in denial of coverage or rescission.

Risk Management / Diligence Practices

Please indicate the risk management practices currently implemented by the insured.

Written safety program in place
Formal employee training records maintained
Background checks for employees / contractors
Periodic site inspections performed
Contractual risk transfer (indemnity/insurance) with subcontractors

Claims History (last 5 years)

If none, check:

Documentation Checklist

Provide supporting documents where applicable. Check items attached or available upon request.

Incident reports
Photographs of loss or conditions
Repair estimates
Invoices / Bills
Relevant contracts / agreements
Medical records (if bodily injury)
Police reports

Beneficiary / Certificate Holder

Declaration and Certification

The undersigned declares that the information contained in this Insurance GL Diligent Form is true, complete, and accurate to the best of their knowledge. The insured understands that material misrepresentation, omission, or failure to disclose exposures or prior losses may constitute grounds for denial of coverage or rescission of the policy. The insured authorizes the insurer, its representatives and authorized agents to obtain loss history, underwriting and inspection reports related to this application, and to rely upon such information in underwriting and issuing coverage.

The insured agrees to maintain reasonable controls to manage identified risks and to provide requested documentation to the insurer on a timely basis. Endorsements, additional insured status, and waiver of subrogation are effective only if specifically issued in writing by the insurer and when the required premium or conditions have been satisfied.

By signing below, the undersigned certifies the foregoing and acknowledges that this form is part of the application and underwriting file.

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