Insurance Optional Coverage Form

INSURANCE OPTIONAL COVERAGE FORM

Insurer Name:    Policy Number:

Applicant / Insured Information

Policy Details

Policy Type:    Effective Date:    Expiration Date:

Optional Coverages (Select to Add)

  Medical Payments Coverage (Optional) — Provides payment for medical expenses regardless of fault. Additional premium applies.

  Weapon/Firearm Liability Endorsement — Extends coverage to incidents involving firearms as described in the endorsement. Subject to underwriting approval and surcharge.

  Waiver of Subrogation — Waives insurer's right to seek recovery from a third party where required by contract. May increase premium or alter recovery rights.

  Deductible Buy-Down — Reduces the insured deductible in exchange for increased premium. Specific terms are listed below.

Exclusions and Limitations

The optional coverages selected above are subject to all terms, conditions, exclusions and limits of the policy. Specific additional exclusions or limitations applicable to selected options will be attached as endorsement(s). The insured acknowledges that the following specific exclusions shall apply unless otherwise agreed in writing:

Beneficiary / Payee Designation (if applicable)

List beneficiaries for optional coverages that provide payment upon loss or death. The insured's designation below supersedes prior designations solely for the selected optional coverages.

Acknowledgments, Representations and Consent

By signing below, the insured certifies that the information provided in this Optional Coverage Form is true and complete to the best of the insured's knowledge. The insured acknowledges that:

1. Any optional coverage selected becomes effective only upon endorsement issuance and premium payment as required by the insurer.
2. The insurer may require additional underwriting, inspection, or documentation prior to acceptance of certain optional coverages.
3. The insured authorizes the insurer to charge the additional premium shown on this form to the policy account and accepts any adjusted terms or endorsements associated with selected options.
4. The insured understands that selected optional coverages may alter defenses, limits, or subrogation rights; such changes will be set forth in the endorsement language.

Consent to Premium Adjustment:   I authorize the insurer to apply additional premium and/or surcharges as a condition of adding the selected optional coverages.

Representation of Accuracy:   I represent that all statements made herein are accurate and complete. I understand that material misrepresentation may result in denial of coverage or rescission consistent with policy terms and applicable law.

Office Use / Underwriting

Underwriter Notes:

Endorsement Required:   Yes      No

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