Insurance Policy Document Pages

INSURANCE POLICY DOCUMENT PAGES

Applicant / Insured Information

Date of Birth:

Policy Details

Policy Number:

Property    Liability    Auto    Life    Other

Coverage Limit (aggregate where applicable): $   Deductible: $

Premium (annual): $

Policy Period: From   to  

Coverage Selections and Limits

Liability Coverage — Each Occurrence Limit: $

Property / Dwelling — Per Occurrence Limit: $   Coverage A Deductible: $

Comprehensive (if applicable) — Limit: $   Deductible: $

Medical Payments — Per Person Limit: $

Exclusions and Limitations

The coverage provided by this policy does not apply to loss or liability arising directly or indirectly from the following, unless expressly endorsed: intentional acts or criminal conduct by the insured; wear and tear, gradual deterioration, latent defects; war, invasion, insurrection, nuclear hazard; pollution except where specifically provided; fraudulent claims or material misrepresentation. No coverage is afforded for punitive damages except where required by law.

Additional limitations, conditions precedent to coverage, and sub-limits are set forth in the Conditions and Endorsements pages attached to this document. The insurer reserves the right to deny coverage where insured fails to comply with notice, cooperation, or proof-of-loss requirements set forth in this policy.

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

Beneficiary Designation (if applicable)

Claims Reporting (Illustrative)

Date of Loss:

Declarations, Conditions and Certifications

Insuring Agreement: Subject to the terms, conditions, limits and exclusions of this policy, the insurer will provide coverage for covered losses arising during the policy period for which premium has been paid. Coverage is limited to those coverages selected on the Coverage Selections page and as further described in the Conditions and Endorsements attached hereto.

Representations and Warranty: The insured represents that all statements and information provided in this application and related documents are true, complete and material to the insurer's decision to issue this policy. The insurer may void coverage, rescind the policy, or adjust claims and premiums for material misrepresentation or omission.

Notice and Proof of Loss: The insured shall give timely notice of any loss or claim as required by this policy, cooperate with the insurer in the investigation and defense of claims, and submit such proofs, records and statements as the insurer may reasonably require. Failure to comply may result in denial of coverage.

Subrogation and Recovery: The insurer shall be subrogated to the insured's rights of recovery against third parties to the extent of any payment made under this policy. The insured shall cooperate fully in preserving and enforcing such rights.

Assignment: No assignment of interest under this policy shall bind the insurer unless consented to in writing by an authorized representative of the insurer.

I certify that the information provided in this policy document is true and complete to the best of my knowledge. I understand that issuance of coverage is subject to the terms, conditions and exclusions of the policy. I agree to timely payment of premiums and to cooperate with the insurer in the event of a claim. I acknowledge that fraudulent statements or concealment of material facts may result in denial of benefits or cancellation of coverage.

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