Insurance Indemnity Agreement

INSURANCE INDEMNITY AGREEMENT

This Insurance Indemnity Agreement (the Agreement) is made effective as of by and between Insured Name: and Insurer Name: . Policy Number: .

Applicant / Insured Information

Policy Details

Coverage Selection

Select coverage types included under this Agreement:

Exclusions

The Insurer shall not be liable for loss, cost, or expense arising from the following exclusions unless expressly added by endorsement:

Indemnity and Defense

The Insured hereby agrees to defend, indemnify and hold harmless the Insurer, its affiliates, agents and employees (Indemnitees) from and against any and all losses, liabilities, claims, damages, fines, judgments, costs and expenses, including reasonable attorneys' fees and litigation costs, arising out of or resulting from the acts or omissions of the Insured, its employees, contractors or agents in connection with the subject matter of the Policy, except to the extent caused by the Insurer's gross negligence or willful misconduct.

The Insured's obligation to indemnify shall include the obligation to pay costs of settlement, judgments and amounts paid in the resolution of claims and shall survive termination of the Policy. The aggregate indemnity limit applicable under this Agreement shall be unless otherwise agreed in writing by the parties.

Notice, Claims and Cooperation

The Insured must provide prompt written notice to the Insurer of any claim or circumstance reasonably likely to give rise to a claim under the Policy. Failure to provide prompt notice shall not void coverage unless prejudice to the Insurer is demonstrable.

The Insured shall cooperate fully with the Insurer in the investigation, defense and settlement of claims, including providing documents, statements and access to witnesses and premises. The Insurer shall have the right, but not the obligation, to control the defense or settlement of any claim.

Subrogation and Recovery

To the extent the Insurer makes payment under the Policy, the Insurer shall be subrogated to the Insured's rights of recovery against third parties. The Insured shall execute all documents and take actions reasonably requested to preserve and effectuate such subrogation rights. The Insured shall not compromise or release any claim against a third party without the Insurer's written consent when such compromise would impair the Insurer's subrogation rights.

Limitations, Remedies and Governing Law

The Insured's indemnity obligations shall be subject to any deductible or limits expressly set forth in this Agreement or in the Policy. Except as otherwise provided, remedies available under this Agreement are cumulative. This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction where the Policy is issued.

Statute of Limitations for actions arising under this Agreement:

Representations, Warranties and Certifications

The Insured represents and warrants that all information provided to the Insurer in connection with the Policy is true, complete and accurate to the best of the Insured's knowledge. The Insured certifies that no material fact has been omitted and that any material change in circumstances shall be reported promptly in writing.

Beneficiary Information

If a beneficiary is designated under the Policy or this Agreement, provide the beneficiary information below. Any changes to beneficiary designation must be made in writing and acknowledged by the Insurer where required by law.

Claims and Documentation (If Claiming Indemnity)

Documentation accompanying a claim (check all that apply):

Miscellaneous Provisions

Severability: If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall continue in full force and effect. Amendments: This Agreement may be amended only by a written instrument signed by the Insured and an authorized representative of the Insurer. Successors and Assigns: This Agreement binds and benefits the parties and their respective successors and permitted assigns.

Certification

By signing below, the Insured certifies under penalty of perjury that the information provided in this Agreement is true and correct, that the Insured understands and accepts the indemnity obligations set forth herein, and that the Insured has authority to enter into this Agreement on behalf of any entity identified as the Insured.

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