Insurance Package Document

INSURANCE PACKAGE DOCUMENT

Applicant / Insured Information

Date of birth:    Phone:    Email:

Policy Details

Policy period: From to .

Coverage limit: $    Deductible: $    Annual premium: $

Coverage Selections

Select the coverages to be provided under this policy. Coverage selected is subject to terms, conditions and exclusions stated herein.

Exclusions

The following exclusions and limitations apply to coverage under this policy unless expressly added by endorsement. Standard exclusions include, but are not limited to: intentional acts by the insured, nuclear hazard, war and hostile acts, wear and tear, gradual deterioration, pollution (unless otherwise endorsed), flood and earthquake (unless specifically endorsed), and contractual liability beyond that assumed in a written contract subject to policy terms.

I acknowledge that I have read and understood the exclusions listed above and agree that any coverage provided is subject to those exclusions and to the full terms, conditions and definitions contained in the policy documents.

Beneficiary Designation

Designate primary beneficiaries for proceeds payable on covered events where beneficiary designation is applicable.

Policy Conditions & Claims Requirements

The insured agrees to comply with all policy terms and to furnish proof of loss, permit inspection and examination under oath, and cooperate with the insurer in the investigation and defense of claims. Notice of any loss or occurrence that may give rise to a claim must be provided in writing to the insurer within the time period required by the policy, which is ordinarily not later than 30 days after discovery unless otherwise agreed in writing.

Material misrepresentation, omission or fraudulent declaration by the insured may render the policy voidable or permit denial of coverage for the matter misrepresented. Payments of premiums must be made when due; nonpayment may result in cancellation in accordance with policy cancellation provisions.

Subrogation: To the extent of any payment, the insurer is subrogated to the rights of the insured against any third party. The insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. This policy may contain an arbitration clause. Governing law and jurisdiction may be set by endorsement below.

Documentation Checklist

Attach or provide the following documents with this application/package as applicable:

Declaration and Certification

I, the undersigned, hereby declare that the statements contained in this Insurance Package Document and any attachments are true, complete and correct to the best of my knowledge and belief. I understand that this information will be relied upon by the insurer in determining eligibility and rates for coverage and that any material misstatement or omission may result in denial of coverage, rescission, or adjustment of claims.

I authorize the insurer and its representatives to obtain and verify any information necessary for underwriting and claims handling, including but not limited to prior insurance, claims history, and relevant records. I agree to provide reasonable cooperation in the investigation and settlement of any claim and to notify the insurer promptly of any circumstance that may give rise to a claim.

By signing below I certify that I have read and accept the terms, conditions, exclusions and obligations set forth in this document and I request the insurance coverages as selected. I understand that coverage is not in force until accepted and issued by the insurer and any required premium is paid as specified in the policy documents.

Agent / Broker (if applicable)

Agency:    License / Broker ID:

Acknowledgment

By signing below the insured acknowledges receipt of this Insurance Package Document, affirms the accuracy of the information provided, and understands that final coverage, limits and terms will be set forth in the issued policy and any endorsements.

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