Insurance Package Applications

INSURANCE PACKAGE APPLICATIONS

Applicant / Insured Information

Individual Corporation Partnership Trust Other

Policy Details

Coverage Selection

Select desired coverages. For each selected coverage indicate the requested limit and deductible. Coverage premiums will be determined following underwriting review.

Property Insurance — Limit $ Deductible $

General Liability — Limit $ Per occurrence Deductible $

Professional Liability (E&O) — Limit $ Deductible $

Commercial Auto — Limit $ Deductible $

Cyber Liability — Limit $ Deductible $

Workers' Compensation — State:

Flood — Limit $ Earthquake — Limit $

Other:

Exclusions and Material Facts

The following represent typical exclusions and are not exhaustive: intentional acts, fraudulent acts, pollution not reported at inception, war, nuclear hazard, and any loss or exposure specifically excluded by endorsement. Coverage is subject to the policy terms, conditions, limitations and exclusions contained within the issued policy.

Applicant must disclose all material facts and prior losses. Failure to disclose a material fact or submission of false information may result in rescission of coverage or denial of claims.

I acknowledge that I have read and understand the typical exclusions and the requirement to disclose material facts.

Beneficiary Designation (if applicable)

Designate primary beneficiaries for policies that include payable death benefits. Percentages must total 100%.

Claims History

Has the applicant had any claims, incidents, or losses in the past five (5) years?

Yes No

Documentation Checklist

Please attach or provide the following documents as applicable. Failure to provide requested documentation may delay underwriting.

Copy of government-issued photo ID

Prior policy declarations / loss runs (last 3 years)

Financial statements (if applicable)

Relevant contracts or client agreements

Declarations and Certification

The undersigned declares that the information provided in this application is true, complete and correct to the best of their knowledge. The undersigned understands that this information will be relied upon by the insurer in evaluating the application and that material misrepresentation or omission may result in denial of coverage or rescission of any policy issued.

The undersigned authorizes the insurer and its agents to obtain and verify information from third parties, including but not limited to prior insurers, loss history repositories, and other relevant data sources. The undersigned consents to the release of relevant information to reinsurers, auditors, and as required by law.

The applicant agrees that completion of this application does not bind coverage. Coverage becomes effective only upon issuance of a policy or binder and payment of any required premium. Any coverage bound is subject to the terms, conditions, endorsements, and exclusions of the issued policy.

By signing below the applicant certifies under penalty of perjury that the statements in this application are true and complete.

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