Insurance Liability Renewal Application

INSURANCE LIABILITY RENEWAL APPLICATION

Applicant Name:    Doing Business As:

APPLICANT / INSURED INFORMATION

Individual    Corporation    LLC    Partnership    Other:

CURRENT POLICY / RENEWAL DETAILS

COVERAGE OPTIONS & LIMITS

Select coverages requested for renewal and indicate limits where applicable.

General Liability (Occurrence)    Each Occurrence:    Aggregate:

Products/Completed Operations    Limit:

Professional Liability / Errors & Omissions    Limit:

Employers' Liability    Limit:

Cyber Liability    Limit:

Excess / Umbrella    Limit:

CLAIMS HISTORY (PAST 5 YEARS)

Have there been any claims, suits, incidents or circumstances that could give rise to a claim in the past five (5) years?    Yes    No

If yes, provide details below. Complete all known matters; attach additional sheets if necessary.

If more than two matters, attach a separate sheet signed by the applicant listing date of loss, description, amount paid/reserved, and current status.

EXCLUSIONS & MATERIAL INFORMATION

The applicant understands and agrees that the insurer's acceptance of this renewal application is subject to underwriting approval. The following are examples of common exclusions that may be applied to renewal coverage; this list is illustrative and not exhaustive:

• Claims arising from intentional acts, fraud, or criminal conduct.
• Pollution and environmental liabilities except where specifically endorsed.
• Claims due to contractual liability beyond that assumed in a written contract unless specifically agreed.
• Claims arising from professional services unless professional liability coverage is selected.

Applicant must disclose all material facts and prior or pending claims; failure to disclose material information or any material misrepresentation shall be grounds for rescission or denial of coverage in accordance with policy terms and applicable law.

BENEFICIARY / CLAIM PAYEE / CERTIFICATE HOLDER

Primary Claim Payee / Certificate Holder Name:

DECLARATION AND AUTHORIZATION

The undersigned applicant declares that the statements contained in this renewal application are true and complete to the best of their knowledge. The applicant understands that this application becomes a part of the policy if issued and that any material misrepresentation, omission, or concealment of fact may result in denial of coverage or rescission of the policy.

The applicant authorizes the insurer to make any investigation of loss history, operations, or other information deemed necessary in connection with this renewal. The applicant further authorizes release of claim or underwriting information to and from prior insurers or their representatives for purposes of underwriting and servicing the policy.

Coverage requested by this application will not be binding until the insurer accepts this application and issues a renewal policy or endorsement specifying the terms, conditions, limitations, and premium. Any oral or written quotation of coverage, premium, or terms provided prior to issuance is an estimate and does not bind the insurer.

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