Insurance IO Application Form

INSURANCE IO APPLICATION FORM

1. Applicant / Insured Information

Date of Birth:

Entity Type: Individual Partnership Corporation LLC Trust Other

2. Policy Details

Policy Type (select all that apply): Property General Liability Professional Liability Marine (Inland/Ocean) Auto Cyber Other

Proposed Policy Period: From to

3. Coverage Options

Select coverages requested and indicate limit where required:

Property Damage — Limit: $

Business Interruption — Limit: $

Crime Coverage — Limit: $

Equipment Breakdown — Limit: $

Pollution Liability — Limit: $

4. Exclusions and Limitations

The insurer's standard exclusions shall apply unless expressly amended in a written endorsement. Common exclusions include but are not limited to:

• Wear and tear, gradual deterioration, and defects arising from inadequate maintenance;
• Intentional acts or fraudulent conduct by the insured;
• War, nuclear hazard, and government seizure unless otherwise endorsed;
• Losses covered by workers' compensation or employer liability statutes.

5. Beneficiary Designation

6. Claims History & Loss Information

Have you or any proposed insured had any claims, losses, or suits in the last five years? Yes No

7. Documentation Checklist

Documents attached: Prior policies Loss runs Photos / inventory Financial statements Other

8. Declarations and Certification

By signing below, the applicant certifies that the statements made in this application are true and complete to the best of the applicant's knowledge. The applicant acknowledges that any material misrepresentation, omission, or concealment of fact in this application or in any supporting document may be grounds for denial of coverage or rescission of the policy. The applicant authorizes the insurer and its agents to obtain and exchange information necessary to underwrite and service the policy, including but not limited to prior insurance, claims history, credit, and public records.

The applicant understands that coverage is not binding until accepted by the insurer and, where applicable, the premium is paid in accordance with the binder or policy terms. Any coverage quotes furnished prior to issuance of a policy are estimates only and do not guarantee insurability.

9. Fraud Warning

Any person who knowingly presents a false or fraudulent claim, statement or application for insurance may be guilty of a criminal offense and subject to civil penalties. Applicable fraud warnings and penalties under state law apply.

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