Insurance Indemnity Deed

INSURANCE INDEMNITY DEED

This Insurance Indemnity Deed ("Deed") is executed by the undersigned Indemnitor for the benefit of the Insurer and the designated Beneficiary. The undersigned agrees to be legally bound by the covenants, conditions and provisions set forth below.

Parties and Insured Information

Indemnitor Name:

Date of Birth:   Tax/ID Number (if applicable):

Policy Details

Coverage Amount:   Deductible:   Premium:

Policy Period From:   To:

Coverage Selections

Select applicable coverage types (check all that apply):

General Liability     Professional Liability     Property Damage
Workers' Compensation     Cyber Liability     Other:

Indemnity Covenant

In consideration of the premiums paid and other good and valuable consideration, the Indemnitor hereby covenants, warrants and agrees as a deed to indemnify and hold harmless the Insurer, its successors, assigns and the Beneficiary designated below (collectively "Indemnified Parties") from and against any and all losses, liabilities, damages, costs, expenses, claims, fines, penalties and legal fees (including reasonable attorneys' fees and costs of investigation and defense) ("Indemnified Losses") arising out of or in connection with any Claim under the Policy identified above, subject to the terms, limitations and exclusions set forth in this Deed.

The Indemnitor acknowledges that this indemnity is primary and shall apply irrespective of any insurance, self-insurance or other risk-transfer mechanism available to any Indemnified Party and shall attach notwithstanding any act, omission, breach of warranty or misrepresentation by any Insured, except to the extent the Indemnified Losses result from the gross negligence or willful misconduct of an Indemnified Party proven by clear and convincing evidence.

Exclusions

The indemnity provided herein shall not apply to Indemnified Losses to the extent arising directly from:

Intentional misconduct or fraudulent acts of the Indemnitor     Criminal acts
Punitive or exemplary damages where such damages are not insurable     War, invasion, insurrection, nuclear or radioactive contamination
Ordinary wear and tear, gradual deterioration, or inherent vice

Conditions and Claims Handling

The Indemnitor's obligations under this Deed are conditioned upon the following:

(a) Prompt written notice to the Indemnitor by the Indemnified Party of any Claim for which indemnity is sought; notice shall be given to the address specified in this Deed and shall include reasonable details of the Claim.

(b) Reasonable cooperation by Indemnified Parties in the defense, settlement and resolution of Claims; the Indemnitor shall not, without the prior written consent of the Indemnified Party, settle any Claim in a manner that imposes liability or other obligation on any Indemnified Party.

Beneficiary Designation

Relationship to Indemnitor:     Beneficiary Percentage: %

Primary Beneficiary     Contingent Beneficiary

Documentation and Estimated Loss

Documentation provided (check all that apply):

Photographs     Police Report     Repair Estimate
Receipts and Invoices     Witness Statements     Other:

Limitations, Remedies and Subrogation

The Indemnitor's liability under this Deed shall not exceed the Coverage Amount stated above, less any applicable deductible. The rights of Indemnified Parties to seek recovery under this Deed are cumulative and in addition to any other rights or remedies available at law or in equity. Upon payment of any Indemnified Losses under this Deed, the Indemnitor shall be subrogated to the rights of the Indemnified Party to pursue recovery from third parties, and Indemnified Parties shall execute such instruments and take such actions as reasonably requested to effectuate such subrogation.

Governing Law and Miscellaneous

This Deed shall be governed by and construed in accordance with the laws selected by the parties. Governing jurisdiction: . If any provision of this Deed is determined to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

This Deed constitutes the entire agreement between the parties with respect to the subject matter hereof and may be amended only by a written instrument executed by the Indemnitor and the Indemnified Party to be charged.

Certification and Execution

The Indemnitor certifies that all information provided in this Deed is true and correct to the best of the Indemnitor's knowledge and that the Indemnitor has full authority to execute and deliver this Deed and to perform its obligations hereunder. This Deed is delivered and intended to be binding as a deed upon execution by the Indemnitor.

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