Insurance GL-PL Application

INSURANCE GL-PL APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Corporation Limited Liability Company (LLC) Partnership Other

Policy Details Requested

Policy Type: General Liability Professional Liability Combined GL-PL

Requested Policy Period: From to

Operations, Exposures & Limits of Liability

Do you enter into written contracts that require additional insured or hold harmless language? Yes No

Coverage Options & Limits (Select)

Bodily Injury & Property Damage Liability Personal & Advertising Injury Products-Completed Operations Medical Payments

Claims-Made Occurrence Prior Acts Coverage

Exclusions & Acknowledgments

The policy applied for will contain standard exclusions for fraud, intentional acts, pollution, professional acts outside the scope of declared services, and punitive damages where prohibited by law. Applicant acknowledges the insurer may apply additional exclusions or endorsements based upon the exposures disclosed.

Applicant acknowledges having read and understood the common exclusions and authorizes the insurer to propose endorsements necessary to address identified hazards. Applicant acknowledges

Prior Insurance & Loss History

Have there been any claims, suits, incidents or losses in the past five (5) years? Yes No

Additional Insureds / Claim Payee / Beneficiary

Relationship to Applicant:

Percentage of Payment to Beneficiary:

Supporting Documentation Checklist

Please attach or provide prior policy declarations, loss runs, and any sample contracts. The insurer may request additional documentation to evaluate coverage.

Prior Policy Declarations Provided: Yes No

Loss Runs Provided (past 5 years): Yes No

Declarations, Authorizations & Certification

The undersigned certifies that the information provided in this application is complete and accurate to the best of the applicant's knowledge. The undersigned acknowledges that the insurer will rely upon these statements in determining eligibility and premium and that any material misrepresentation, omission or concealment may result in the denial of coverage, rescission of the policy or denial of claims.

The applicant authorizes the insurer and its representatives to obtain loss history, claim information, underwriting, and other relevant records from prior insurers, claim handlers, or other sources. The applicant further authorizes the release of underwriting and claims information to designated parties for underwriting and risk management purposes.

By signing below the applicant certifies that no other person or entity has been omitted from this application whose operations or activities should reasonably be expected to be insured under the policy applied for. The applicant understands that coverage will be subject to the policy terms, conditions, limitations and exclusions contained in the policy issued.

Any person who knowingly submits false information with the intent to defraud may be subject to criminal and civil penalties, including denial of coverage and claim payment.

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