Insurance Policy Renewal Declaration

INSURANCE POLICY RENEWAL DECLARATION

Policy Number:    Insured Name:

Insured Information

Date of Birth:

Policy Details

Homeowners    Automobile    General Liability    Commercial Property

Renewal Term Start:    Renewal Term End:

Coverage Options

Select coverages to be included in the renewal. Checking a box authorizes inclusion of that coverage subject to underwriting approval and payment of the additional premium where applicable.

Bodily Injury & Property Damage Liability
Comprehensive
Collision
Uninsured/Underinsured Motorist
Personal Property Replacement Cost
Flood Coverage (if available)

Exclusions and Material Changes

The renewal will not expand coverage to matters specifically excluded by the existing policy or by underwriting action at renewal. Typical exclusions include, but are not limited to: intentional acts, wear and tear, war, nuclear hazard, and losses sustained while committing unlawful acts.

I represent that, since the inception of the current policy, there have been no material changes to the risk except as disclosed below. A material change includes changes in occupancy, usage, condition, ownership, or any change that increases the likelihood or severity of a covered loss.

I have reported all claims or losses incurred during the prior policy term as required by the policy conditions.

Beneficiary Designation

Designate primary beneficiaries for any policy proceeds payable to the insured or as otherwise provided in the policy.

Declaration and Certification

I, the undersigned Applicant, declare under penalty of perjury that the information provided in this Renewal Declaration is true, correct, and complete to the best of my knowledge. I acknowledge that any material misrepresentation, omission, or concealment of fact may void coverage or permit the insurer to rescind or deny claims under the renewed policy to the extent permitted by law.

I understand and agree that this declaration does not itself bind the insurer to issue a renewal; the insurer's agreement to renew is conditioned upon underwriting review, payment of any required premium, and the absence of undisclosed material change. I authorize the insurer and its representatives to obtain and verify information relevant to underwriting and claims, including but not limited to inspection reports and prior loss history.

I further acknowledge receipt of the renewal terms stated by the insurer (which may be provided separately) and authorize the insurer to charge the premium due for the renewed policy to the payment method on file or as otherwise authorized in writing.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim or material fact in connection with an application for insurance may be subject to criminal and civil penalties as provided by law.

I hereby certify the foregoing and affirm that I have read and understand the terms of this Renewal Declaration.

Payment and Binding Authorization

By signing below I authorize billing for any renewal premium and fees associated with the renewed policy. I understand that failure to remit required premium by the due date may result in cancellation or lapse in coverage in accordance with policy provisions.

Authorization & Signature

By signing, I represent that I am authorized to act on behalf of the named insured and to request renewal under the terms indicated in this declaration. I understand that this signature is an attestation under oath to the accuracy of the information provided herein.

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