Insurance Liability Coverage Application

INSURANCE LIABILITY COVERAGE APPLICATION

Applicant / Insured Information

Date of Birth (if individual applicant): Month Day Year

Policy Details Requested

Desired policy type (check all that apply):

General Liability    Professional Liability (E&O)    Products/Completed Operations    Employers' Liability / Employers' Practices    Commercial Auto Liability

Desired Policy Period Effective Date: Month Day Year

Requested Policy Period End Date: Month Day Year

Coverage Options (select and specify limits where requested)

Bodily Injury Liability — Limit per person/occurrence:

Property Damage Liability — Limit per occurrence:

Personal & Advertising Injury — Limit:

Medical Payments — Per person:

Exclusions and Terms

The proposed policy will exclude coverage for claims arising directly or indirectly from: intentional acts or willful misconduct; pollution and environmental impairment unless specifically endorsed; asbestos and lead-related liabilities unless specifically endorsed; punitive or exemplary damages to the extent uninsurable by law; war, nuclear hazard, and criminal acts. Additional exclusions may apply and will be set forth in the policy language.

By checking the box below the applicant acknowledges review of the primary exclusions above and consents that making a material misrepresentation may void coverage and permit rescission of the policy.

Applicant acknowledges and understands the exclusions and material misrepresentation consequences.

Loss / Claims History (most recent five years)

Have you had any liability claims, suits, or incidents that may give rise to a claim in the past five years? Yes    No

Claim / Incident 1

Date of Loss: Month Day Year

Claim / Incident 2

Date of Loss: Month Day Year

Claim / Incident 3

Date of Loss: Month Day Year

Beneficiary / Payee Designation (if applicable)

Liability policies typically do not name beneficiaries in the manner of life insurance. This section is for designation of a payee for returned premiums or recovery subrogation reimbursement only.

Declarations and Authorization

The undersigned declares that the information supplied in this application is true, complete and correctly recorded. The applicant warrants that no material facts have been withheld. The applicant understands that this application, including any attachments and statements, shall form the basis of the insurance contract if a policy is issued.

The applicant authorizes the insurer, its representatives and legal designees to make any investigation of credit, employment, premises, operations and prior loss history necessary to evaluate this application. The applicant agrees to notify the insurer of any material change in the facts set forth herein prior to policy inception.

Fraud Warning: It is a crime to knowingly provide false, incomplete or misleading information to obtain insurance. Such acts may be grounds for denial of coverage, rescission of the policy, civil remedies, and prosecution under applicable laws.

By checking the box below the applicant certifies that they have read and agree to the declarations above and that the information provided is accurate to the best of their knowledge.

Applicant certifies accuracy of statements and authorizes investigation.

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