Insurance Package Renewal Form

Insurance Package Renewal Form

Applicant Name:   Policy Number:

1. Applicant / Insured Information

Contact phone:   Email:

Date of birth / Incorporation date:   Tax ID / SSN:

2. Current Policy Details

Commercial Package Policy    Business Owners Policy (BOP)    General Liability    Property    Commercial Auto    Workers' Compensation

Policy effective date:   Policy expiration date:

3. Renewal Options & Requested Changes

Renewal requested: Renew on same terms    Renew with endorsements    Do not renew / request cancellation

Payment frequency:   Billing instruction:

4. Risk & Underwriting Questions

In the last 12 months, has any insured had a claim, loss, or occurrence that may give rise to a claim? Yes No

Have there been material changes to operations, employees, locations, or revenue since the last policy period? Yes No

5. Coverage Selection

Property Coverage — Limit: Deductible:

General Liability — Limit: Deductible:

Commercial Auto — Limit per vehicle: Deductible:

Workers' Compensation — Limits as required by statute

6. Exclusions & Acknowledgements

The following are typical exclusions which may apply to renewal: intentional acts, pollution unless endorsed, war, wear and tear, nuclear hazard, and fraudulent acts by insured. Endorsements may be required to provide limited coverage for excluded risks.

I acknowledge that I have read the exclusions above and that failure to disclose known exposures or material changes in risk may result in denial of coverage, rescission, or non-renewal. Acknowledged

7. Beneficiary / Loss Payee / Additional Insured

Relationship:   Share/Interest (%):

8. Attachments / Documentation Checklist

Please attach the following documents with this renewal submission:

Current loss runs (past 5 years)

Financial statements (if requested)

Inspection reports / safety audits

Vehicle schedule / equipment schedule

9. Privacy, Authorization & Payment

By signing below, the Applicant authorizes the insurer and its authorized representatives to obtain and use underwriting, claims, credit, and other information relevant to underwriting and renewal decisions. The Applicant authorizes disclosure of such information to affiliates, reinsurers, and service providers for underwriting and claim handling purposes.

The Applicant authorizes payment of premiums as indicated. If payment terms are not satisfied, the insurer may suspend coverage in accordance with policy terms and applicable law.

10. Declarations and Certification

The Applicant certifies that all statements and information contained in this renewal form are true and complete to the best of the Applicant's knowledge. The Applicant understands that any material misrepresentation, omission, or concealment of facts may be cause for rescission, denial of coverage or denial of claim benefits, and may affect coverage under any renewed policy.

The Applicant agrees that the insurer may decline renewal, modify terms, or require additional premium based upon the insurer's review of the information provided, inspections, loss history and other underwriting information. Renewal will be effective only upon issuance of renewal documentation or endorsement by the insurer or its authorized agent.

Fraud Warning: Any person who knowingly presents false information in an application for insurance may be subject to civil or criminal penalties under applicable law.

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