Insurance Important Notice

INSURANCE IMPORTANT NOTICE

Insured / Applicant Information

Insured Name:

Mailing Address:

Date of Birth:

Policy Details

Coverage Selections

Select all coverages that are included under this policy and verify limits and endorsements below.

Liability Coverage — protects against legal liability for bodily injury and property damage.

Property Coverage — covers physical loss or damage to insured property.

Comprehensive Coverage — loss by theft, vandalism, fire, or other non-collision perils.

Collision Coverage — damage resulting from collision with another vehicle or object.

Uninsured/Underinsured Motorist Coverage — protects insured when at fault by uninsured party.

Medical Payments — medical expense coverage regardless of fault.

Exclusions and Limitations

The following are common exclusions under the standard form. This notice summarizes principal exclusions; the policy contract and any endorsements govern the actual coverage and exclusions.

Common exclusions include but are not limited to: intentional acts or criminal acts by the insured; wear and tear, gradual deterioration, and mechanical breakdown; losses arising from nuclear hazard, war and certain acts of terrorism as defined in the policy; losses expressly excluded by endorsement; and coverage exclusions for business pursuits unless endorsed.

Beneficiary Designation

Primary Beneficiary Name:

Relationship: Percentage:

Claim Reporting and Proof of Loss

Prompt reporting of claims is a condition precedent to coverage. Failure to report within required timeframes may result in denial. When reporting a claim, provide the following information and documentation where applicable.

Date of Loss:

Documentation submitted with initial claim (check all that apply):

Police Report

Photographs of Damage

Repair/Replacement Estimate

Medical Records / Bills

Important Legal Notices and Certifications

Material Misrepresentation: Any false statement, misrepresentation of a material fact, or omission made with respect to an application for insurance or in the presentation of a claim may constitute fraud and may be grounds for denial of coverage, rescission of the policy, or voiding of the claim where permitted by law.

Duty to Cooperate: The insured must cooperate with the insurer's reasonable investigation of any claim, including providing signed statements, requested documentation, and reasonable access to inspect damaged property.

Subrogation: To the extent of any payment, the insurer may pursue recovery from third parties responsible for loss. The insured shall execute all documents required to secure the insurer's subrogation rights.

Cancellation and Nonrenewal: Policy cancellation or nonrenewal will be governed by the terms of the policy and applicable law. Refunds for premiums, if any, will be calculated in accordance with the policy provisions and applicable statutes.

By signing below, I certify that I have received this Insurance Important Notice; that I have read and understand the summaries and warnings above; that the information I have provided on this form is true and complete to the best of my knowledge; and that I understand the policy document and endorsements control my rights and obligations under the contract of insurance.

I acknowledge that failure to disclose material information may result in denial of claims, rescission of coverage, or other remedies available to the insurer.

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