Insurance Hazard Disclosure

INSURANCE HAZARD DISCLOSURE

Applicant / Insured:   Policy Number:

Insurer (if known):   Date Prepared:

Applicant Information

Policy Details

Policy Type (check all that apply):

Homeowners   Commercial Property   Dwelling Fire   Flood   Liability   Umbrella

Policy Period: From to

Known Hazards and Property Characteristics

Indicate presence of the following conditions at the insured location (check all that apply):

Fire damage history   Flood or recurrent water intrusion   Earthquake vulnerability   Mold or chronic moisture

Wind/hail exposure   Prior theft or vandalism   Known liability hazards (e.g., unsafe conditions)   Environmental/pollution risks

Prior Losses and Claims

Have there been any losses, claims, or damage events at this location in the past 10 years? Yes   No

Environmental and Structural Conditions

Disclose existence of the following (check all that apply) and provide details where indicated:

Asbestos   Lead-based paint   Mold contamination   Underground storage tanks

Building Systems and Safety Features

Indicate safety systems in place:

Smoke detectors   Sprinkler system   Security/alarm system   Fire extinguishers

Exclusions, Acknowledgments and Applicant Certification

The applicant certifies that the information provided in this Hazard Disclosure is true, complete and accurate to the best of the applicant's knowledge. Applicant understands that any material misrepresentation or omission of fact relating to known hazards or prior losses may result in denial of coverage, rescission of the policy, or adjustment of coverage terms and premium. The insurer shall have the right to verify statements contained in this disclosure, including inspection of the insured property and review of claim history.

Applicant acknowledges that certain hazards may be subject to specific exclusions or limitations under the policy and that disclosure does not in itself create coverage for every disclosed condition. Applicant further acknowledges obligation to notify the insurer promptly of any change in condition that materially increases the risk of loss.

I have read and understand the statements and acknowledgments above and affirm the accuracy of the disclosures contained herein.

Beneficiary Designation (if applicable)

Provide beneficiary information where policy provisions allow designation of beneficiary for settlement proceeds.

Additional beneficiaries may be attached by separate signed schedule and incorporated by reference into this disclosure.

Certification

By signing below, the applicant certifies under penalty of perjury that the foregoing statements are true and complete. Applicant authorizes the insurer and its representatives to obtain such information as may be necessary to verify statements made herein and to investigate previously reported losses or known hazards. Applicant understands that this disclosure is part of the application for insurance and is relied upon by the insurer in determining insurability and policy terms.

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