Insurance Limits Change Form

INSURANCE LIMITS CHANGE FORM

Insured / Applicant Information

Policy Details and Requested Change

Policy Type: Auto Homeowners Commercial Auto General Liability Umbrella Workers' Compensation Professional Liability Life/AD&D

Other policy type (if applicable):

Requested effective date of change:    Requested processing preference: As of 12:01 AM on effective date As of 12:00 PM on effective date

Limits — Current and Requested

Bodily Injury — Per Person:   Current: $   Requested: $

Bodily Injury — Per Accident:   Current: $   Requested: $

Property Damage:   Current: $   Requested: $

Each Occurrence / Per Claim:   Current: $   Requested: $

Annual Aggregate:   Current: $   Requested: $

Umbrella / Excess Limit:   Current: $   Requested: $

Deductible and Premium

Coverage Lines Affected

Select all coverage lines to which the requested limit change applies:

Bodily Injury Property Damage Each Occurrence / Claim Aggregate Limits Umbrella/Excess Deductible

Exclusions, Restrictions, or Endorsements

Reason for Change

Beneficiary / Additional Insured Information (if applicable)

Applicant Declaration and Authorization

By signing below, the Applicant certifies that the information provided on this Insurance Limits Change Form is true and complete to the best of the Applicant's knowledge. Applicant acknowledges and agrees that:

1. Any change to policy limits is subject to underwriting approval and acceptance by the insurer; the insurer may impose additional terms, endorsements, or premium adjustments as a condition of effecting the requested change.

2. The effective date requested on this form will not be binding until accepted in writing by the insurer or its authorized representative. Premium adjustments and pro rata calculations, if applicable, will be determined by the insurer.

3. Material misrepresentation, omission, or failure to notify the insurer of changes in risk may result in denial of the requested change, cancellation, or rescission of coverage, to the extent permitted by law and the policy.

4. Applicant authorizes the insurer and its authorized agents to obtain and use underwriting information necessary to evaluate and process this request, including claim history and loss runs.

5. Applicant understands that this form is an instruction to request a limits change and does not, by itself, modify or create coverage until the insurer issues confirmation or an endorsement.

Applicant hereby certifies under penalty of perjury that the foregoing statements are true and correct and that the Applicant is authorized to request this change on behalf of the named insured.

I authorize the insurer to process this limits change request and acknowledge potential premium and policy adjustments.

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