Insurance Offer Form

INSURANCE OFFER FORM

Insurer Name:

Offer Number:    Offer Date:

1. Applicant / Insured Information

Date of Birth:    Phone:    Email:

2. Policy Details (Offer Terms)

Personal Auto    Homeowners    Renters    Commercial General Liability

Professional Liability    Life    Health    Other:

Policy Period: From to    Payment Frequency:

3. Coverages Offered

The following coverages are offered under this policy (limits and conditions apply). Applicant must indicate acceptance of each coverage to bind that coverage.

Bodily Injury Liability    Property Damage Liability    Comprehensive    Collision

Personal Liability    Medical Payments    Theft    Fire

Flood    Business Interruption    Errors & Omissions    Employers' Liability

4. Exclusions and Conditions

The offer is subject to the policy terms, standard exclusions and any endorsements specified below. Standard exclusions include, without limitation, losses arising from intentional acts, war, nuclear hazard, fraudulent claims, and losses excluded by endorsement. Applicant acknowledges review of the exclusions and conditions identified in this offer.

Applicant acknowledges receipt and review of standard exclusions and conditions described in this document.

5. Beneficiary Designation (if applicable)

Primary Beneficiary Name:

Relationship:    Allocation Percentage:

6. Required Documentation Checklist

The applicant must provide the following documentation prior to policy inception. Check boxes indicate documents provided with this offer acceptance.

Government-issued identification    Proof of address    Prior policy declarations    Property / Vehicle photos

Medical records (if required)    Business financial records (if required)

7. Additional Terms and Material Disclosures

Applicant must disclose all material facts known to Applicant that are relevant to the risk being insured. Material misrepresentation or omission of facts is grounds for rescission or denial of coverage as permitted by law. This offer is expressly conditioned on the truthfulness and completeness of information provided to the insurer.

8. Applicant Certification and Acceptance

By signing below, the Applicant certifies that all statements and representations made in this Insurance Offer Form and any attachments are true, complete and correct to the best of Applicant's knowledge. Applicant acknowledges and agrees that:

1. The insurer's obligation to provide coverage is conditioned on receipt of the initial premium, completion of any required underwriting, verification of submitted documentation, and acceptance by the insurer. Coverage will not be effective until the insurer issues a policy and confirms the effective date in writing.

2. Material misrepresentation or failure to disclose relevant information may result in denial of claims, cancellation or rescission of coverage, and may affect the validity of this offer. Applicant consents to reasonable investigations, including underwriting inquiries and as permitted, credit or background checks necessary to evaluate the risk.

3. Applicant understands that endorsements, limitations and special conditions may be attached to the policy; such provisions are considered part of the policy and take precedence where they conflict with standard terms.

I, the undersigned Applicant, have read this Insurance Offer Form and accept the offered terms and coverages checked above, subject to issuance of the policy by the insurer and payment of the premium.

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