Insurance Liability Sign Packet

INSURANCE LIABILITY SIGN PACKET

This Insurance Liability Sign Packet collects applicant and policy information, confirms acceptance of coverage terms and exclusions, and records certifications and authorizations required by the insurer. Applicant acknowledges that the information provided in this packet will form the basis for underwriting and issuance of any liability insurance policy.

Applicant / Insured Information

Applicant Name:

Individual LLC Corporation Other

Policy Details

General Liability Professional Liability Product Liability Auto Liability Other

Policy Period: From to

Coverage Options & Limits

Select coverages and specify limits where applicable. Absence of a selected coverage indicates it is not included unless endorsed in the policy schedule.

Bodily Injury Liability — Limit:

Property Damage Liability — Limit:

Defense Costs / Legal Expenses — Sublimit:

Medical Payments — Limit:

Exclusions and Limitations

The policy excludes coverage for losses arising from: (a) intentional acts or deliberate wrongdoing by the insured; (b) bodily injury or property damage expected or intended from the insured's standpoint; (c) liabilities assumed under a contract beyond those deemed insured by the policy; (d) losses arising from war, nuclear hazard, and government seizure; (e) pollution and environmental damage except where a specific endorsement provides coverage; (f) punitive, exemplary, or multiplied damages to the extent such damages are uninsurable under applicable law. Any additional exclusions contained in the policy wording or endorsements supersede representations in this packet.

Applicant Acknowledgment: I acknowledge that I have read and understand the principal exclusions and limitations that may apply to this policy.

Beneficiary / Loss Payee Information

Primary Beneficiary Name:

Documentation Checklist

Please provide the following documentation with this packet. Check each item included:

Copy of government-issued ID Loss history / claim runs Relevant contracts / certificates

Photographs or documentation of operations Other attachments

Declarations, Authorizations, and Certifications

By signing this packet, the applicant certifies that the statements and facts contained herein are true, complete, and accurate to the best of the applicant’s knowledge. Applicant understands that any material misrepresentation, omission or concealment may render the policy voidable or may lead to denial of coverage or claim payments.

Applicant grants the insurer and its authorized representatives the right to obtain and verify information relevant to underwriting and claims handling, including but not limited to loss history, prior insurance, and financial responsibility. Applicant authorizes third parties to release such information upon request.

Applicant understands that coverage is subject to the terms, conditions, exclusions and endorsements of the issued policy. Nothing in this packet alters, amends, or extends coverage beyond what is set forth in the final policy documents. In the event of conflict, the policy terms and endorsements govern.

Subrogation: Applicant agrees to cooperate with the insurer in the pursuit of recovery from liable third parties, and to execute instruments necessary to secure such rights on behalf of the insurer where permitted by law.

Privacy and Use of Information: Applicant acknowledges that personal and business information provided is necessary for policy issuance and administration and may be used for underwriting, claims handling, and fraud prevention consistent with applicable law.

Loss Reporting / Claims Notice

In addition to policy notice requirements, any event likely to give rise to a claim must be reported promptly. Timely notice helps preserve coverage and assists in claims investigation and defense.

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