Insurance Office Application

INSURANCE OFFICE APPLICATION

Applicant / Insured Information

Applicant Name:

Contact Phone:    Contact Email:

Date of Birth (if individual applicant):

Individual    Corporation    LLC    Partnership    Other:

Office / Location Details

Number of Employees:    Square Footage of Office:

Policy Details Requested

General Liability    Property    Professional Liability (E&O)    Workers' Compensation    Business Auto    Cyber Liability    Other:

Desired Coverage Amount:    Desired Deductible:

Preferred Premium Payment Frequency:

Policy Period Requested From: to

Coverage Options and Limits

Limits requested (per occurrence / aggregate):

Crime/Fidelity    Business Interruption    Equipment Breakdown    Contents Coverage    Tenant Improvements (TIV)   

Known Exclusions, Limitations, and Prior Losses

Have any claims been litigated or resulted in judgment against the applicant? Yes No

Beneficiary / Payee Designation (if applicable)

Relationship:    Percent of Benefit: %

Relationship:    Percent of Benefit: %

Documentation Checklist

Please attach or indicate documents enclosed with this application:

Business License / Registration    Financial Statements    Prior Insurance Policies    Loss Runs (past 5 years)    Site Plans / Floor Plans

Declarations, Authorizations, and Certification

The undersigned applicant certifies that the information contained in this application and any attachments is true, complete and accurate to the best of the applicant's knowledge. The applicant understands that coverage will be issued based upon the representations made herein and that any material misstatement, omission or concealment may result in policy rescission, denial of coverage for a claim, or termination of coverage.

The applicant authorizes the insurer and its representatives to obtain and review underwriting, claims, loss history, credit, financial and other records reasonably related to the underwriting and administration of the policy, and to disclose such information to reinsurers and other parties as necessary for underwriting and claims handling. This authorization remains in effect for the life of the policy and for a reasonable period thereafter insofar as necessary for audit, loss recovery or other legitimate purposes.

The applicant acknowledges that issuance of an insurance policy is subject to the insurer's underwriting guidelines, assessments and the terms, conditions, limitations and exclusions of the policy. No agent or broker may bind coverage except by express written authority from the insurer.

By checking the box below, the applicant consents to receive policy documents, billing statements and communications in electronic form where permitted by law. I consent

Acknowledgement of Fraud Warnings

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud under applicable law and subject to civil and criminal penalties.

Signature and Certification

By signing below, the applicant certifies under penalty of perjury that the statements in this application are true and complete to the best of their knowledge and that they have the authority to execute this application on behalf of the named insured.

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