Insurance Hazard Certificate

INSURANCE HAZARD CERTIFICATE

Applicant Name:   Policy Number:

Applicant / Insured Information

Property / Location Information

Property type:    Year built:

Policy Details

Coverage limit: $    Deductible: $    Annual premium: $

Policy period from to

Inspection and Assessment

Date of inspection:    Inspector name:

Fire risk    Flood risk    Earthquake/structural risk

Mold/biological hazard    Chemical/HAZMAT    Electrical hazard

Overall risk rating:   Estimated probability of loss:

Mitigation and Controls

Documentation Checklist

Photographs of hazards    Inspection report attached    Receipts for recent repairs

Exclusions and Limitations

The presence or absence of identified hazards in this Certificate does not amend, extend, or alter any insurance policy or coverage. Unless expressly endorsed to the policy, the following standard exclusions apply and are not limited to:

(a) losses arising from pre-existing latent defects not disclosed to the insurer; (b) losses caused by delayed remediation where timely action was required; (c) consequential losses including business interruption except as specifically insured; and (d) losses caused by intentional acts or gross negligence of the insured.

Applicant acknowledges the above exclusions:

Certification and Applicant Declaration

I certify that I am authorized to provide the information contained herein on behalf of the named insured. I declare under penalty of perjury that the statements and representations contained in this Insurance Hazard Certificate are true, complete, and correct to the best of my knowledge. I understand that this Certificate is provided for underwriting and loss-prevention purposes and that the insurer may rely upon the accuracy of the statements herein in determining eligibility for coverage, premium, and terms. I acknowledge that omission of material facts or submission of false information may result in denial of coverage or rescission of the policy.

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