Insurance Policy Delivery Requirements

INSURANCE POLICY DELIVERY REQUIREMENTS

Insurer Name:     Policy Number:

APPLICANT / INSURED INFORMATION

POLICY DETAILS

Policy Period: From through

DELIVERY METHOD AND AUTHORIZATION

The Insured elects the following method for delivery of policy documents. The Insured acknowledges that delivery by the selected method satisfies the Insurer's delivery obligations unless otherwise specified in the policy.

Mail to mailing address on file
Electronic delivery to email address on file
Deliver to appointed agent/broker
In-person delivery to insured

REQUIRED DOCUMENTS CHECKLIST

The following documents are required to be delivered to the Insured, broker, or agent as applicable. Indicate items included with issuance of this policy.

Declarations Page(s)
Full Policy Text / Policy Jacket
Endorsements and Riders
Initial Premium Invoice / Receipt
Notice of Right to Cancel (if applicable)
Prior Loss History (if provided)
Other (describe below)

COVERAGE SECTIONS AND OPTIONS

The documents to be delivered will include the coverage sections indicated below. Check all that apply and specify limits where required.

Liability Coverage
Property Coverage
Auto / Auto Liability
Workers' Compensation
Professional Liability / E&O
Medical Payments / Personal Injury Protection

EXCLUSIONS, ENDORSEMENTS, AND CONDITIONS

The Insured acknowledges that the policy and delivered endorsements contain exclusions, limitations, and conditions that may affect coverage. Common exclusions may include but are not limited to: intentional acts, pollution, contractual liability where excluded, war and nuclear hazards except as provided in applicable endorsements. Delivery of the full policy text and endorsements is required for a complete understanding of exclusions.

BENEFICIARY DESIGNATION (IF APPLICABLE)

Complete only if the policy provides for a beneficiary designation.

DECLARATION AND CERTIFICATION

By signing below, the Insured certifies that the information provided on this form is true and complete to the best of the Insured's knowledge. The Insured acknowledges receipt of the documents indicated above, or has authorized the Insurer to deliver the indicated documents by the selected method. The Insured further acknowledges that coverage is subject to the terms, conditions, declarations, endorsements, and exclusions contained in the policy documents, and that failure to deliver required documents in a timely manner may affect the exercise of certain rights under the policy.

The Insured understands that electronic delivery, where selected, is consented to for all required policy documents unless revoked in writing. Proof of delivery by mail, electronic transmission, or agent delivery shall be sufficient to establish delivery. Any questions about the scope of coverage or specific endorsements should be raised with the Insurer or appointed agent prior to reliance on coverage.

I acknowledge that I have received the documents checked above or have authorized electronic delivery and understand the delivery requirements and conditions.

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