Insurance Incentive Coverage Form

INSURANCE INCENTIVE COVERAGE FORM

Applicant / Insured Information

Date of birth:

Policy Details

Policy type: General Liability Property Auto Workers' Compensation Other

Policy period: From through

Incentive Coverage Election

Select incentive(s) to apply to the policy. For each selected incentive provide the applicable credit percentage or flat amount and any implementation date.

Premium credit Credit:

Claims-free credit Credit:

Safety program rebate Amount/Percentage:

Loss control grant Grant amount:

Renewable energy installation credit Credit:

Telematics / monitoring discount Discount:

Exclusions and Limitations

The incentives elected herein are subject to verification, audit and compliance review by the insurer. Incentives shall not increase the insurer's limit of liability under the policy unless expressly set forth in a written endorsement signed by an authorized representative of the insurer. Incentives will be void if based upon materially false or misleading information, if the insured fails to implement or maintain the qualifying measures, or if the insured fails to timely provide required documentation for verification.

The insurer's liability for any incentive-related adjustment is limited to the amount of premium credit or rebate expressly identified and accepted in writing. Incentives do not create coverage for losses otherwise excluded by the policy. The insurer reserves the right to rescind or modify incentives in the event of fraud, material misrepresentation, or significant change in exposure.

By initialing below the insured acknowledges and accepts the exclusions and limitations above. Initials:

Documentation Checklist

Attach or provide the following documentation as applicable; failure to provide required documentation may delay or void incentives.

Safety inspection report

Proof of purchase / installation (invoices, receipts)

Training certificates or attendance logs

Photographs of implemented measures

Other supporting documentation Description:

Beneficiary Designation (if incentive is payable)

Beneficiary Name:

Relationship to insured: Percentage allocation:

Declaration and Certification

I, the undersigned applicant or authorized representative, declare under penalty of perjury that the information provided in this Insurance Incentive Coverage Form and any attached documentation is true, complete and accurate to the best of my knowledge. I acknowledge that incentives are granted only upon satisfactory verification by the insurer and that the insurer may seek additional documentation or perform on-site inspections to confirm eligibility.

I authorize the insurer and its designated representatives to obtain records and information necessary to verify eligibility for elected incentives and understand that failure to cooperate with verification requests may result in forfeiture of incentives and adjustment of premiums or coverage. I acknowledge that acceptance of an incentive requires compliance with the terms set forth in this form and any applicable policy endorsements.

I further understand that incentives granted for risk control measures do not constitute a representation that the insured premises are free of hazards, nor do they alter the insured's duty to maintain reasonable care and safe operations. Acceptance of incentives does not create any third-party rights beyond those in the underlying policy and governing law.

By signing below I certify that I am authorized to bind the Named Insured and that I have read, understand and agree to the terms, exclusions and conditions of this Insurance Incentive Coverage Form.

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