Insurance Highlighted Form

INSURANCE HIGHLIGHTED FORM

Applicant / Insured Information

Date of Birth:    Phone:

Policy Summary

Policy Number:    Policy Type:

Annual Premium:    Policy Period From: to

Coverage Highlights

Property Damage — coverage for physical damage to insured property subject to limits and deductible.

Bodily Injury Liability — coverage for legal liability arising from bodily injury to third parties.

Personal Property — coverage for personal property owned by the insured, subject to sub-limits.

Theft and Vandalism — protection for loss from theft or malicious damage where not otherwise excluded.

Fire and Smoke — standard peril coverage for fire and sudden smoke damage.

Flood — explicitly noted; unless selected, flood is excluded and requires separate endorsement.

Exclusions and Limitations

The following are customary exclusions under this policy form unless otherwise endorsed. The insured acknowledges these may limit recovery and should consult the full policy contract for operative terms.

• War, hostilities, and nuclear hazard exclusions;
• Intentional acts and criminal activity by insured or beneficiaries;
• Wear and tear, gradual deterioration, and maintenance-related loss;
• Certain professional liability and punitive damages exclusions;
• Specified perils excluded by endorsement (e.g., flood, earthquake) unless added.

Beneficiary Designation

Beneficiary Name:    Relationship:    Percentage:

Beneficiary Name:    Relationship:    Percentage:

Claims Notice & Documentation (If applicable)

Date of Loss:

Documentation submitted with claim (check applicable):

Police Report

Photographs of Loss

Receipts / Invoices

Repair Estimates

Declaration and Certification

By signing below, the applicant certifies under penalty of law that all information provided in this Insurance Highlighted Form is true, complete, and accurate to the best of the applicant's knowledge. The applicant acknowledges that this form is a summary of key policy features only and does not replace the full insurance policy contract, endorsements, or declarations page, which govern coverage, terms, conditions, limitations, and exclusions.

The applicant further authorizes the insurer to verify any information provided, to obtain relevant loss history, and to request documentation necessary to underwrite coverage or to process claims. Misrepresentation or material omission in the application or claims process may result in denial of coverage or rescission of the policy in accordance with contract terms and applicable law.

Fraud Warning: Any person who, with intent to defraud or knowing that they are facilitating a fraud against an insurer, submits an application or statement containing materially false information may be guilty of insurance fraud and subject to civil and criminal penalties.

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