Insurance Policy Quote Request

INSURANCE POLICY QUOTE REQUEST

Applicant / Insured Information

Individual Corporation LLC Trust Other

Date of Birth:    Social Security / TIN:

Policy Details Requested

Desired Policy Type: Auto Homeowners Renters Commercial General Liability Professional Liability Umbrella

Coverage Options

Select additional coverages to include in the quote (if applicable):

Property Damage Bodily Injury Liability Medical Payments Personal Injury Protection Theft Coverage Flood (optional) Earthquake (optional)

Property / Risk Details (if applicable)

Construction Type:    Year Built:    Occupancy:

Prior Claims / Loss History

Within the last 5 years, has the applicant had any claims or losses? Yes No

Underwriting / Material Information

Has any insurer declined, cancelled, or non-renewed coverage for the applicant in the past 5 years? Yes No

Are there any ongoing or planned operations, renovations, or exposures materially different from prior declarations? Yes No

Beneficiary Designation (if applicable)

Provide primary beneficiaries for this policy. Percentages must total 100%.

Documentation Checklist

Please indicate which supporting documents you will provide with this request:

Prior policy declarations Photographs of risk / property Loss / police reports Repair/repair estimates Financial statements (for commercial risks)

Declarations and Authorizations

I certify that the information provided in this Insurance Policy Quote Request is true, complete, and submitted for the purpose of obtaining an insurance quotation. I understand that this request is not an insurance policy and that any quote issued is preliminary and subject to underwriting review, inspection, and verification of all material facts.

I authorize the insurer, its agents, and affiliates to obtain and verify underwriting, credit, loss history, and other relevant information about me or the insured, including by contacting prior insurers, credit reporting and claims databases, and through public records as necessary to evaluate this request and to issue a quote or policy. I agree that any material misrepresentation or omission may be grounds to deny coverage or rescind any policy issued.

I acknowledge that the insurer may rely on the representations in this request and that quotes are valid only for the time period specified in the quotation document. Premiums, coverage, terms, and conditions are subject to change upon issuance of the policy and final underwriting approval.

Broker / Agent (if applicable)

Exclusions / Special Instructions

Acknowledgment

By signing below I represent that I am authorized to request this quote on behalf of the named insured. I understand that any quote provided will be based upon the information supplied and is conditional on satisfactory completion of any required inspections, supplemental applications, and verification of the information provided herein.

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