Insurance Liability Form

INSURANCE LIABILITY FORM

Applicant / Insured Information

Policy Details

Policy Number:    Policyholder Type: Individual Entity

Policy Period From: to

Coverage Selections

Select the liability coverages to be provided under the policy. Checked boxes indicate requested coverages; acceptance is subject to underwriting and policy terms.

General Liability — bodily injury and property damage arising from operations and premises.

Product Liability — claims arising from products sold or supplied.

Professional Liability / Errors & Omissions — negligent acts, errors or omissions in professional services.

Cyber Liability — privacy breach, network security and data breach liability.

Automobile Liability — liability from use of owned, non-owned or hired vehicles.

Umbrella / Excess Liability — excess limits over primary policies.

Exclusions and Acknowledgments

The following items are commonly excluded from liability coverage unless explicitly endorsed. Applicant acknowledges review of each item indicated below and understands that coverage is limited to the terms, conditions and endorsements of the issued policy.

Intentional or criminal acts by the insured.

War, military action or hostile acts exclusion.

Pollution, contamination and environmental damage (unless specifically endorsed).

Professional services exclusion (subject to Professional Liability endorsement).

Contractual liability limitation applies as stated in policy.

Beneficiary / Payee Designation

Designate the person(s) or entity(ies) to receive any payable proceeds under this policy in the event of a covered loss requiring payment to the insured's estate or assignee.

Notice of Occurrence / Claim Reporting (if applicable)

For occurrences that may give rise to a claim, provide the following information. Notification to the insurer must be given as soon as practicable in accordance with policy conditions.

Documentation Checklist (attached / to follow):

Photographs of damage or scene

Police or incident reports

Receipts, estimates or invoices

Witness statements or contact information

Declaration and Certification

By signing below, the Applicant declares that the information provided in this Insurance Liability Form is true and complete to the best of Applicant's knowledge. Applicant acknowledges that any material misrepresentation, omission or failure to disclose relevant facts may result in denial of coverage, cancellation of the policy, or rescission ab initio where permitted by law.

Applicant authorizes the insurer and its representatives to obtain, review and exchange underwriting, claims and loss information, and to make any investigations deemed necessary to determine coverage or to defend any claim. Applicant agrees to cooperate fully in the investigation and processing of claims and to furnish proofs of loss, documentation, and releases as required by the insurer.

Unless otherwise stated in an issued policy or endorsement, the insurer retains all rights of subrogation and recovery against third parties to the extent of any payments made under the policy. Premium, coverage acceptance, limitations and exclusions are subject to underwriting approval and issuance of a policy or endorsement setting forth complete terms and conditions.

Applicant understands that completion of this form does not constitute acceptance of coverage. Coverage is effective only as set forth in a policy document issued by the insurer and delivered to the policyholder.

Acknowledgment of Fraud and Privacy

Any person who knowingly presents false information in an application for insurance may be subject to civil and criminal penalties. Applicant acknowledges receipt of any notices regarding information practices and consents to the insurer's use of information for underwriting, claims handling and fraud prevention as permitted by law.

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