Insurance GL Sign Packet

INSURANCE GL SIGN PACKET

Applicant / Insured Information

Date of Birth:

Policy Summary

Policy Type:

Policy Number:

Policy Period: From to

Limits of Liability:

Deductible: Premium (annual):

Coverages (select applicable)

General Liability (Occurrence)
Products / Completed Operations
Personal & Advertising Injury
Damage to Premises Rented to You
Medical Payments

Endorsements and Additional Coverages

Exclusions and Important Notices

The policy contains exclusions and limitations which may include but are not limited to: intentional acts, professional liability, pollution unless endorsed, and contractual liability except as provided by endorsement. By signing below, the insured acknowledges receipt of the exclusions summary and understands that coverage is subject to policy terms, conditions and exclusions contained in the final policy form.

Premium Payment and Billing

Payment Plan Selected: Annual Installment Deferred

Prior Claims / Loss History

Has the insured had any claims, suits, or incidents in the last five (5) years that could give rise to a claim under this policy? Yes No

Beneficiary / Additional Insured Designation

Primary Additional Insured Name:

Declarations and Authorizations

The undersigned declares that the information contained in this packet is true and complete to the best of the insured's knowledge. The insured understands that any material misrepresentation, omission or concealment of facts may result in denial of coverage, rescission of the policy or other remedies provided by law. The insured authorizes the insurer and its representatives to obtain such information as necessary to underwrite and service the policy, including claims history and verification of statements made herein.

Fraud Notice: Where applicable by law, any person who knowingly submits false information, or conceals information with the intent to defraud, may be subject to civil and criminal penalties. The insured affirms the foregoing statements have been read and understood.

Agent / Broker Acknowledgement

The agent certifies that the above policy information and applicant statements have been accurately recorded and that the applicant has been provided necessary policy disclosures required by law and underwriting practice.

Optional - Inspection / Loss Control Authorization

The insured grants permission for the insurer or its authorized representative to inspect premises related to this policy and to obtain supporting documentation related to exposures and loss experience. Such inspection is for underwriting and loss control purposes and does not alter coverage unless expressly endorsed.

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