Insurance Liability Declaration

INSURANCE LIABILITY DECLARATION

Applicant / Insured Information

Policy Details

Coverage Selected (select all that apply)

Bodily Injury Liability
Property Damage Liability
Personal/Advertising Injury
Products / Completed Operations Liability
Professional Liability / Errors & Omissions
Cyber Liability / Data Breach
Other (describe):

Exclusions and Acknowledgements

The undersigned acknowledges that the policy identified above may contain exclusions, limitations, or endorsements that restrict coverage. The undersigned certifies awareness of the following standard exclusions unless specifically endorsed:

• Intentional acts and willful misconduct
• Punitive or exemplary damages where uninsurable by law
• Contractual liability except as specifically provided by endorsement
• Pollution or environmental damage unless specifically covered
• Claims arising from professional services unless professional liability is endorsed

I acknowledge that I have reviewed these common exclusions and either (i) understand they apply to my policy, or (ii) have requested and obtained specific endorsements that alter these exclusions. Confirm acknowledgement: Yes

Beneficiary / Additional Insured Information

Claims and Loss History

Within the past five (5) years, has the applicant had any liability claims, suits, or incidents that could give rise to a claim? Yes No

Declaration and Certification

I, the undersigned Applicant, declare under penalty of perjury that the information provided in this Insurance Liability Declaration is true, complete and accurate to the best of my knowledge. I acknowledge that this Declaration is made for the purpose of inducing the Insurer to issue or continue the policy referenced above and that material misrepresentation, omission or concealment of fact may result in denial of coverage, rescission of the policy, or voidance of coverage for affected claims.

I further certify that I have disclosed all facts known to me that are material to the underwriting of the policy, including prior claims or circumstances that may reasonably give rise to a claim. I agree to cooperate fully with the Insurer in the investigation and defense of any claim and to provide prompt written notice of any occurrence that may give rise to a claim under the policy.

By signing this Declaration I authorize the Insurer to obtain and review my claims history and underwriting records relevant to the policy. I understand that coverage afforded is subject to policy terms, conditions, limits and endorsements.

Authorization and Release

I authorize release of information contained in this Declaration to other insurers and authorized representatives for purposes of underwriting, claims handling and fraud prevention. I understand that this authorization shall remain in effect for the duration of the policy and for a reasonable period thereafter for purposes of claims handling.

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