Insurance Liability Waiver

INSURANCE LIABILITY WAIVER

Applicant / Insured Information

Client Name:

Date of Birth:    Phone:    Email:

Policy Details

Coverage Amount: $    Deductible: $    Annual Premium: $

Policy Period: From to

Covered Activities / Insured Property

Coverage Selections

Select coverages to which this waiver applies (check all that apply):

General liability for bodily injury and property damage
Product liability (if applicable)
Property damage coverage
Personal injury / advertising injury

Exclusions and Acknowledgements

The following exclusions apply to this waiver unless expressly added by endorsement. Acknowledgement required for each exclusion:

Intentional acts, criminal conduct, or willful misconduct
War, invasion, terrorist acts, and civil commotion
Pollution, contamination, and hazardous waste (unless endorsed)
Liability assumed under contract beyond standard obligations

Initial to acknowledge that you have read and accept the exclusions listed above:

Beneficiary Designation (for indemnity or payable amounts)

Beneficiary Name:

Relationship:    Percentage: %

Declaration, Release and Certification

By signing this Insurance Liability Waiver I, the undersigned Applicant, declare and certify that the information provided above is true, complete, and accurate to the best of my knowledge. I expressly authorize the insurer, its agents, representatives, and any named indemnitees to rely upon the statements in this Waiver.

I voluntarily assume all risks of loss, damage, or injury to persons or property arising out of the activities or property described above to the extent permitted by applicable law. I hereby release, waive, discharge, and covenant not to sue the insurer, its agents, officers, employees, contractors, volunteers, and any parties otherwise covered by this policy (collectively, the Released Parties) from any and all liability for loss, damage, or injury, including death, that may arise from the covered activities, except for losses caused by the Released Parties' gross negligence or willful misconduct where such exclusion is prohibited by law.

I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all claims, demands, liabilities, judgments, losses, damages, costs and expenses (including reasonable attorneys' fees) arising out of or resulting from my breach of this Waiver or my negligent acts or omissions in connection with the covered activities, except to the extent such indemnity is prohibited by law.

I acknowledge that this Waiver does not amend or bind any insurance policy beyond the scope set forth in the Policy Details and that any coverage is subject to policy terms, conditions, limitations and exclusions. I further certify that I will cooperate with any loss investigation and provide truthful information and documentation upon request.

I understand that making a false or fraudulent statement or submitting false documentation in connection with this Waiver or any related claim may subject me to civil or criminal penalties under applicable law.

Severability: If any provision of this Waiver is found to be unenforceable, the remainder shall remain in full force and effect. Governing Law: This Waiver shall be governed by the laws of the jurisdiction in which the insured risk is located, to the extent not preempted by applicable federal law.

Consent: I consent to the release and use of my information by the insurer for underwriting, claims handling, and regulatory reporting as required by law. I further authorize that payments, if any, due under this Waiver or related policy may be made to the designated beneficiary above.

Sign Now