Insurance Policy Binder

INSURANCE POLICY BINDER

Binder Identification

Binder Number:     Date of Issuance:

Insurer and Agent

Agent Contact:     Agency License #:

Applicant / Insured Information

Date of Birth:     Tax ID / SSN (insured):

Policy Summary

Policy Number (if assigned):     Premium (total): $

Effective Date:     Expiration Date:

Coverages and Limits

The following coverages are bound by this binder subject to the terms, conditions and exclusions stated herein. Check applicable coverages and specify limits and deductibles where required.

  Property Insurance — Limit: $   Deductible: $

  General Liability — Limit: $   Retained Limit / Deductible: $

  Automobile (Business Auto) — Limit: $   Deductible: $

  Cyber Liability — Limit: $   Retention: $

  Professional Liability / E&O — Limit: $   Deductible: $

  Other:

Endorsements, Conditions and Exclusions

This binder evidences that subject to the terms and conditions stated below, the Insurer will bind coverage described above until the earlier of issuance of the formal policy, cancellation in accordance with the terms herein, or the expiration date stated in this binder.

Conditions Precedent and Documentation

Coverage under this binder is conditioned upon receipt and acceptance by the Insurer of all documents and information required by underwriting. The following items are required prior to issuance of a formal policy (initial or check as provided).

  Signed Application

  Loss Runs / Claims History (most recent 5 years)

  Photographs / Inventory / Valuations

  Inspection Report / Survey

  Other Required Documents:

Premium, Payment and Cancellation

This binder may be cancelled by the Insurer in accordance with the cancellation provisions of the final policy and, absent such provisions, by written notice to the Insured. Any return premium will be calculated in accordance with the Insurer's standard short-rate or pro rata schedule as applicable.

Beneficiary Designation (if applicable)

Complete beneficiary information only if the bound coverage contemplates named beneficiaries (e.g., life, disability, or certain fidelity/credit policies).

Relationship:    Share:

Relationship:    Share:

Declarations and Acknowledgment

By signing below, the Applicant represents and warrants that the information provided in connection with this binder is true, complete and accurate to the best of Applicant's knowledge. Applicant acknowledges that this binder is temporary evidence of coverage only and that the full policy will contain terms, conditions, limitations and exclusions which shall govern the coverage. Coverage bound by this binder is subject to the Insurer's receipt and approval of required documentation, payment of premium as agreed, and underwriting approval for issuance of a formal policy.

Applicant acknowledges receipt of this binder and agrees that coverage provided is limited to the coverages and limits expressly stated above. Applicant further agrees to notify the Insurer promptly of any material change in risk and understands that failure to do so may result in rescission or denial of coverage.

Accept and Acknowledge:   I certify that I am authorized to bind the applicant to the terms of this binder.

Administrative Notes (Insurer Use)

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