Insurance Policy Bind Renewal

INSURANCE POLICY BIND RENEWAL

Renewal Notice

Policy Number:    Renewal Effective Date:

This document constitutes an offer to bind renewal coverage subject to the terms, conditions, endorsements and the express conditions to bind listed below. Coverage will be bound only upon acceptance by the insurer and satisfaction of all binding conditions including receipt of required premium or deposit.

Insured / Applicant Information

Individual    Corporation    LLC    Partnership    Trust    Other

Broker / Agent

Policy Details

Property    General Liability    Commercial Auto    Professional Liability    Umbrella/Excess

Coverage Selections and Limits

Property Coverage:   Limit:

Liability Coverage:   Limit:

Auto Coverage:   Limit per vehicle:

Professional Liability:   Aggregate Limit:

Exclusions, Endorsements and Special Conditions

Standard policy form exclusions apply. Additional endorsements required for renewal will be attached to the final policy. The insurer reserves the right to exclude or limit coverage for hazards discovered after binding. Applicant must disclose any unreported exposures for coverage to be effective as bound.

Prior Losses and Claims Disclosure

Have there been any claims, losses or incidents during the prior policy period that could give rise to a claim?   No    Yes

Beneficiary Designation (if applicable)

Complete only if policy contains payable beneficiary provisions.

Conditions to Bind Renewal

Coverage bound by this renewal offer is expressly subject to the following conditions precedent which must be satisfied prior to the insurer's obligation to provide coverage:

1. Receipt of the signed renewal binder form by the insurer or its authorized representative;
2. Payment of the required premium or deposit as indicated by the insurer;
3. Verification of representations and disclosures made by the insured and resolution of any undisclosed adverse exposures;
4. Satisfactory completion of any required inspections, risk improvement measures or underwriting conditions noted by the insurer.

Condition confirmations:
Deposit/Premium Received    Inspection Completed    Required Documents Provided

Declarations and Applicant Certification

By signing below, the insured certifies that the statements made in this renewal form are true, complete and are made for the purpose of inducing the insurer to continue coverage. The insured acknowledges that any material misrepresentation or omission may result in rescission, voidance, denial of coverage or adjustment of terms in accordance with the policy. The insured authorizes the insurer to obtain and disclose underwriting and claim information necessary to effect renewal.

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