Insurance Policy Authorization

INSURANCE POLICY AUTHORIZATION

Applicant / Insured Information

Applicant Name:

Date of Birth:   Social Security / Tax ID:

Policy Details

Policy Type:

Requested Effective Date:   Requested Expiration Date:

Coverage Limit(s):

Deductible:   Estimated Annual Premium:

Coverage Selection

Select coverages to be bound under this authorization (check all that apply):

General Liability
Professional Liability (Errors & Omissions)
Property Insurance (including building & contents)
Commercial Auto
Workers' Compensation
Umbrella / Excess Liability

Exclusions and Limitations

The applicant acknowledges that standard policy exclusions, conditions, limitations, and endorsements may apply. Excluded perils commonly include intentional acts, punitive damages where prohibited by law, wear and tear, war, nuclear hazard, and certain pollution events unless specifically endorsed. The applicant must review the policy wording for complete exclusions.

By checking the box below the applicant acknowledges awareness of typical exclusions and accepts responsibility to request specific endorsements for coverages not included as part of the standard policy form.

I acknowledge that I have read and understand the exclusions and limitations described above.

Beneficiary / Payable Party (if applicable)

Primary Beneficiary Name:

Relationship to Insured:   Allocation Percentage:

Documentation / Supporting Information

Authorization and Certification

I, the undersigned applicant or authorized representative, certify that the information provided in this Insurance Policy Authorization is true, complete, and accurate to the best of my knowledge. I understand that any material misrepresentation, omission, or concealment of fact may permit the insurer to rescind coverage or deny claims to the extent permitted by law.

I authorize the insurer and its agents, representatives, and service providers to obtain, verify, and exchange any information necessary to evaluate this application and any claim hereunder, including but not limited to: loss history, credit information, employment and financial records, and medical records where applicable. I further authorize any person or entity that possesses such information to release it to the insurer, its agents, and representatives.

This authorization permits the insurer to retain photocopies of documents and maintain electronic records. This authorization shall remain effective as long as coverage is in force and for a reasonable period thereafter to allow for claim handling and audit.

Premium Payment Authorization

I authorize the insurer to charge premium amounts, fees, and taxes to the payment method designated below for the purpose of effecting or renewing coverage. I understand that failure to remit required premiums may result in cancellation or nonrenewal of the policy in accordance with the policy terms.

Claims Handling and Notices

In the event of a loss, the insured must provide prompt notice to the insurer in accordance with policy conditions. The insured authorizes the insurer to settle claims, engage counsel, and take such actions as necessary to investigate and resolve claims subject to policy limits and applicable law.

Representations, Remedies and Governing Law

The applicant represents that all statements made herein are material to the risk assumed by the insurer. The insurer's remedies for misrepresentation or omission are governed by the terms of the policy and applicable law, which may include rescission, denial of coverage, or adjustment of premium. Any disputes arising from this authorization or the resulting policy shall be governed by the law of the jurisdiction specified in the policy.

Acknowledgment

By signing below I attest under penalty of perjury that I am authorized to bind the applicant to this Insurance Policy Authorization and that the information provided is true and complete. I understand that coverage will be bound only after acceptance by the insurer and in accordance with the terms, conditions, and endorsements of the policy issued.

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