Insurance Policy Holder Choice

INSURANCE POLICY HOLDER CHOICE

Applicant / Insured Information

Applicant/Insured Name:

Date of Birth:     Address:

Designation of Policy Holder

I hereby elect the following policy holder designation. Select one option and complete the designated policy holder information.

  Individual Policy Holder (applicant serves as policy holder)

  Entity Policy Holder (designated organization or other legal entity)

Policy Details

Insurer Name:     Policy Number:

Policy Period Start:     Policy Period End:

Coverage Elections

Select the coverages to be bound under this policy. Indicate limits or deductibles where applicable.

  General Liability — Limit:

  Property / Buildings — Insured Value:

  Collision — Deductible:

  Comprehensive — Deductible:

  Medical Payments — Limit:

  Uninsured / Underinsured Motorist — Limit:

Exclusions and Limitations

The coverages elected are subject to the standard policy terms, conditions, exclusions and endorsements issued by the insurer. Common exclusions include intentional acts, contractual liability beyond the policy's insurable limits, wear and tear, pollution not covered by endorsement, and loss arising from illegal activity. This selection does not expand coverage beyond policy language.

Beneficiary / Payee Designation

Designate one or more beneficiaries to receive policy proceeds payable upon covered loss or upon termination where applicable. Total must equal 100%.

Declaration and Certification

By signing below, I certify under penalty of law that the information provided in this Insurance Policy Holder Choice form is true, complete and correct to the best of my knowledge. I acknowledge that any material misrepresentation or omission may result in denial of coverage or rescission of the policy in accordance with policy terms and applicable law.

I understand that my designation of the policy holder determines the individual or entity entitled to receive notices, invoices, cancellations and claim communications from the insurer. I further acknowledge that changes to the policy holder designation must be made in writing and accepted by the insurer or its authorized agent before becoming effective.

I authorize the insurer and its agents to verify any information provided, including obtaining underwriting, claims and loss history from prior insurers. I consent to the insurer using the information for underwriting, policy administration and claims handling, subject to applicable privacy laws.

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