Insurance Mutual Application

INSURANCE MUTUAL APPLICATION

Applicant / Insured Information

Applicant Name:

Policy and Coverage Details

Policy Type: Property Liability Auto Life Health Workers' Comp Other:

Policy Period: From to

Specific Coverages & Limits

Select coverage options and indicate limit where required.

Buildings / Real Property — Limit: $

Contents / Business Personal Property — Limit: $

General Liability — Each Occurrence: $

Auto Liability — Combined Single Limit: $

Employment Practices Liability — Limit: $

Cyber Liability — Limit: $

Insured Risk Information

Loss History & Prior Coverage

Have you had any claims, losses, or incidents in the past five (5) years? Yes No

Prior insurer (most recent): Policy period:

Safety, Security & Loss Control

Does the applicant maintain the following? (check all that apply)

Fire alarm / suppression system
Security / intrusion alarm
Formal employee safety training program
Regular maintenance and inspections

Beneficiary Designation

Beneficiary 1 Name: Relationship: Share %:

Beneficiary 2 Name: Relationship: Share %:

Applications Attachments & Documentation

Please indicate which documents are attached to this application:

Loss runs (last 5 years)
Financial statements
Safety policies / procedures
Prior policy declarations

Exclusions, Conditions & Member Mutual Provisions

The applicant acknowledges and agrees that coverage afforded by any policy issued in reliance on this application will be subject to standard policy exclusions, including but not limited to:

(a) Losses arising from willful acts, intentional misconduct, or fraudulent acts by the insured; (b) material misrepresentation or omission in this application; (c) war, nuclear hazard, and certain pollution events as defined in the policy; and (d) other exclusions set forth in the policy form and endorsements.

As a member of the mutual, the applicant understands that membership entitles the insured to the rights and obligations described in the mutual's bylaws, including potential assessments for extraordinary losses and participation in pool governance under terms set by the mutual's governing documents and policy contract.

Applicant Initials:

Declarations, Authorization & Certification

I certify, on behalf of the applicant, that the information provided in this application and any attachments is true, complete and accurate to the best of my knowledge. I understand that the mutual and its representatives will rely on this information in evaluating insurability and establishing terms, conditions and premium. I further acknowledge that any material misstatement or omission may be grounds for denial of coverage, rescission of policy, or other remedies available at law or equity.

I authorize the mutual, its agents, and authorized representatives to obtain information necessary to evaluate this application, including but not limited to loss history, credit information, inspection reports, and other underwriting data. I understand that this authorization survives the termination of any resulting policy for purposes related to claim handling, audit, or investigation.

I agree to abide by applicable policy terms and the mutual's rules and bylaws, to pay premiums as billed, and to cooperate in any audits, inspections, and investigations reasonably requested by the mutual. I understand premiums may be subject to audit and adjustment.

WARNING: Any person who knowingly submits false information or conceals material facts may be subject to civil and criminal penalties under applicable law.

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