Insurance Liability Increase Form

INSURANCE LIABILITY INCREASE FORM

Applicant / Insured Information

Policy Details — Existing Policy

Current Liability Limit:   Requested Increased Limit:

Requested Effective Date:

Policy Period From:   To:

Coverage Requested

Select coverage lines for which the increased liability limit is requested (check all that apply):

Exposure & Loss Information

Have there been any claims, suits, or circumstances likely to give rise to a claim against the insured since the inception of the policy? No Yes

Exclusions & Acknowledgements

The requested increase, if accepted by the insurer, will be subject to the terms, conditions, limitations and exclusions of the existing policy and any endorsement issued to implement the increase. Typical exclusions include—but are not limited to—intentional acts, nuclear hazards, pollution (unless specifically endorsed), and punitive damages where not insurable by law. The insured acknowledges that the insurer may require underwriting information, inspection, or loss runs prior to acceptance.

Initial to acknowledge you have read and understand the foregoing exclusions and the insurer's right to underwrite or decline the requested increase:

Documentation Checklist

Please indicate which documents are attached to support this request:

Beneficiary / Payee Information (If applicable)

Certain payments under liability policies (for example, settlement payees or loss payees) may be directed to a third party. Provide beneficiary or payee details only if a named third party should receive settlement proceeds.

Declaration and Certification

I hereby request an increase in liability limits as set forth in this form. I represent and warrant that the information provided is true, correct and complete to the best of my knowledge and belief. I acknowledge that any material misrepresentation or omission may result in denial of the requested increase and may affect coverage under the policy. I authorize the insurer and its representatives to make any investigations and inquiries deemed necessary in connection with this request, including obtaining loss history and inspection reports.

I understand and agree that the requested increase is not effective until accepted by the insurer in writing or by issuance of an endorsement. I further acknowledge that acceptance may result in additional premium, changes in terms or conditions, or requirement of additional underwriting information. I agree to promptly notify the insurer of any change in the facts contained herein that occur prior to issuance of any endorsement implementing the increase.

By signing below I certify under penalty of perjury that the foregoing statements are accurate and that I am authorized to request this change on behalf of the named insured.

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