Insurance Liability Application Form

Insurance Liability Application Form

Applicant / Insured Information

Date of Birth:

Individual    Sole Proprietorship    Corporation    LLC    Partnership    Other:

Policy Details

General Liability    Professional Liability (E&O)    Product Liability    Commercial Auto Liability    Employers' Liability    Other:

Policy Period (Requested) From: To:

Coverage Options & Endorsements

Additional coverages requested:
Bodily Injury    Property Damage    Personal & Advertising Injury    Products/Completed Operations    Waiver of Subrogation    Deductible Buyback

Operations, Exposure & Loss History

Annual gross receipts / revenue:

Has any insurer declined, canceled or refused renewal of liability coverage? Yes   No

Exclusions

Applicant acknowledges that standard liability policies exclude certain risks. Applicant initial or check each acknowledgement:
Intentional acts or expected injury    Pollution and environmental hazards    Professional services (unless professional liability purchased)
War, nuclear or similar hazards    Employee injuries covered by workers' compensation

Beneficiary / Loss Payee (If applicable)

Loss Payee / Beneficiary Name:

Relationship to Insured:    Percentage of interest:

Declarations, Authorizations and Certifications

The undersigned applicant certifies that the information contained in this application is true, complete and correct to the best of applicant's knowledge and belief. Applicant acknowledges that any material misrepresentation, omission or concealment of fact may result in denial of coverage or rescission of the policy.

Applicant further authorizes the insurer and its representatives to obtain underwriting, loss history, credit, motor vehicle, and other relevant consumer or commercial reports, and to disclose information to reinsurers, agents and to the extent required by law. Coverage is subject to underwriting review and issuance of a policy by the insurer; submission of this application does not bind coverage.

Applicant agrees to notify the insurer promptly of any change in material facts or operations and understands that premiums quoted are based on the information provided. Applicant acknowledges receipt of the notice regarding fraud warnings where applicable and understands that intentional false statements may be a criminal offense.

By signing below the applicant certifies that all statements in this application are made under penalty of perjury and that the signatory has authority to execute this application on behalf of the named applicant.

I certify that the foregoing representations are true and authorize the insurer to investigate the statements contained herein.

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