Insurance PAQ Form

INSURANCE PAQ FORM

1. Applicant / Insured Information

Individual Corporation LLC Other:

2. Policy Details

Proposed Policy Type General Liability Property Professional Liability Cyber Liability Other:

3. Coverage Options and Limits

Select coverages requested and specify limits where applicable.

Liability Coverage — Limit: $

Property Coverage — Limit: $

Business Interruption — Limit: $

Equipment Breakdown — Limit: $

Cyber Liability — Limit: $

4. Exclusions and Known Risks

Standard policy exclusions apply. The following known exposures, circumstances, or prior losses are declared by the applicant and may affect underwriting. Failure to disclose material facts may render coverage voidable.

Have you had any claims, losses, or notices of potential claims in the past five (5) years? No Yes — If yes, describe:

5. Beneficiary Designation

Designate beneficiary(ies) for policy proceeds where applicable. Percentages must total 100% where multiple beneficiaries are named.

6. Documentation Checklist

Please indicate the documents provided with this application. Additional documentation may be required for underwriting.

Financial Statements (most recent)

Prior Insurance Declarations

Loss Runs / Claims History

Other:

7. Declarations, Authorizations and Fraud Warning

I hereby declare that the information provided in this Insurance PAQ Form is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage, rescission of the policy, or voiding of claims. I agree that this form, together with any attachments, becomes part of any policy issued in reliance upon it.

I authorize the insurer and its representatives to obtain loss history, credit, and relevant underwriting information from third-party sources and prior insurers as reasonably necessary to evaluate this application. I authorize release of information to reinsurers, auditors, and regulators where required.

I acknowledge that premium estimates are subject to verification and adjustment based on underwriting results. Binding of coverage is not effective until a policy is issued and premium terms are agreed in writing.

WARNING: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or claim containing materially false information may be subject to criminal and civil penalties, including denial of coverage.

8. Applicant Certification

By signing below I certify that I am authorized to complete this Insurance PAQ Form on behalf of the named applicant and that the statements and particulars herein are accurate and complete. I acknowledge that underwriting may require additional documentation and that I will promptly provide requested materials.

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