Insurance Liability Request

INSURANCE LIABILITY REQUEST

Applicant / Insured Information

Individual Corporation LLC Partnership Other

Date of Birth (if individual):    Place of Business/Principal Location:

Policy Request Details

Policy Type Requested: General Liability Commercial Auto Product Liability Professional Liability Umbrella/Excess Other

Policy Period Requested: From to

Coverage Requested (select and specify limits if different)

Bodily Injury Limit:

Property Damage Limit:

Personal & Advertising Injury Limit:

Products-Completed Operations Limit:

Medical Payments Limit:

Contractual Liability

Non-Owned/Hired Auto Liability

Cyber Liability (if available)

Exclusions Acknowledgement

The undersigned acknowledges that standard liability policies exclude certain losses. Applicant acknowledges review of the following exclusion categories (check those that are material to this request):

Intentional acts or willful misconduct Professional services exclusion Pollution and environmental damage

War, acts of terrorism or similar political acts Nuclear hazard Cyber-related losses (where excluded)

Prior Claims / Loss History

Have any claims or suits been made against the applicant in the past five (5) years? Yes No

Incident / Liability Request Specifics (if applicable)

Date of Incident:    Location of Incident:

Documentation Checklist

Please indicate documents submitted with this request:

Police report Photographs Repair/Repair Estimates

Medical records Invoices/Receipts Contract(s) or agreements

Beneficiary / Payee Information (if applicable)

Declarations and Authorization

The undersigned hereby requests the insurer to consider issuance of liability coverage on the basis of the information provided herein. The applicant represents that the information supplied in this request is true, complete and correct to the best of the applicant’s knowledge and that no material fact has been omitted. Material misrepresentation, omission, or fraudulent statement may result in denial of coverage, rescission of any issued policy, or forfeiture of benefits as permitted by law.

The applicant authorizes the insurer and its representatives to make any investigations and inquiries deemed necessary to evaluate this request, including but not limited to examinations of records, loss runs, and to obtain relevant claim and underwriting information from prior insurers, brokers, or other third parties. The applicant authorizes release of such information for underwriting and claim handling purposes.

This Request for Insurance Liability is an application for underwriting only and does not bind coverage, create any rights inuring to third parties, or commit the insurer to provide insurance. Coverage, if any, will be effective only upon issuance of a written policy or binder signed by an authorized representative of the insurer and upon payment of any required premium. The applicant agrees to promptly disclose any material change in the information presented prior to policy inception.

By signing below the applicant certifies that the signatory has authority to execute this request on behalf of the named insured and acknowledges that false statements made with intent to deceive may constitute insurance fraud under applicable law.

Producer / Broker (if applicable)

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