Insurance LTR Application

INSURANCE LTR APPLICATION

Applicant / Insured Information

Applicant Name:

Individual    Organization / Business    Trust / Estate

Policy Details

Policy Period From: to

Coverage Options (select all that apply)

Liability Coverage
Property Coverage
Business Interruption Coverage
Employment Practices Liability
Cyber Liability
Other:

Exclusions and Limitations

The proposed policy will not cover losses resulting from intentionally wrongful acts, criminal activity, punitive damages where unenforceable by law, war or nuclear hazard as defined in the policy, or other exclusions set forth in the issued policy. Applicant acknowledges the insurer retains sole right to determine and impose specific exclusions and endorsements based on underwriting review.

Beneficiary Designation

Primary Beneficiary Name:

Contingent Relationship:     Allocation %:

Prior Insurance and Loss History

Documentation Checklist

Please attach the following where applicable:
Proof of identity
Prior policy declarations
Loss reports and supporting documentation
Financial statements (if required)

Declarations, Authorizations, and Certifications

I certify that the statements and answers contained in this application are true, complete, and correct to the best of my knowledge. I understand the insurer will rely upon these statements in determining eligibility for issuance of the requested LTR coverage. I authorize the insurer and its designees to obtain and exchange information necessary to evaluate this application, including but not limited to prior insurance records, claims history, and other relevant underwriting information.

I acknowledge that any material misrepresentation, concealment, or omission of fact in this application may be grounds for denial of coverage, rescission of the policy, or other remedies available by law. I understand that coverage, if issued, will be subject to the terms, conditions, limitations and exclusions contained in the policy and any applicable endorsements.

Any person who knowingly submits an application containing materially false, incomplete or misleading information may be subject to civil and criminal penalties, including denial of coverage and reimbursement of claims.

Applicant agrees to pay the required premium, fees and any applicable taxes. Failure to pay premium as required may result in cancellation or nonrenewal of coverage in accordance with the policy terms.

Acknowledgement

By signing below, I acknowledge receipt of this application, confirm the accuracy of information provided herein, and authorize the insurer to process this application and take appropriate underwriting action consistent with the representations made.

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