Insurance Liability Questionnaire

INSURANCE LIABILITY QUESTIONNAIRE

Applicant / Insured Information

Applicant Name:

Date of Birth:

Policy Details

Policy Period From:   To:

Coverage Selections

Select all coverages requested or currently in force:

Bodily Injury Liability    Property Damage Liability    Personal & Advertising Injury

Products/Completed Operations    Medical Payments    Defense Costs Outside Limits

Commercial Auto (liability)    Professional Liability    Other:

Prior Claims / Loss History

Within the past five (5) years, has the applicant had any liability claims, suits, incidents or notices of potential claim?

Yes    No

Operations and Exposures

Exclusions and Limitations

Applicant acknowledges that answers provided in this questionnaire are for underwriting and risk assessment. Coverage granted by any policy is subject to the policy's terms, conditions, limitations and exclusions, including but not limited to exclusions for intentional acts, pollution, war, contractual liability where required by contract beyond standard indemnity, and professional services not specifically endorsed.

Applicant acknowledges receipt of and understanding of the above exclusions and limitations.

Beneficiary / Loss Payee

Beneficiary Name:

Declaration and Certification

I certify that the information contained in this questionnaire is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may void coverage and may be grounds for rescission or denial of claims. I authorize the insurer and its authorized representatives to make inquiries and investigations to verify the information provided, including inspection of premises and review of loss history and claim files. This questionnaire is incorporated by reference into any policy of insurance issued in reliance upon these statements.

Applicant further acknowledges that this questionnaire does not confer coverage, alter the terms of any policy, or create a waiver of policy provisions except as expressly stated in a written endorsement issued by the insurer.

By signing below, the applicant certifies the truthfulness of the statements contained herein and acknowledges that the insurer may rely on this information in determining insurability and policy terms.

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