Insurance Policy Renewal Form

INSURANCE POLICY RENEWAL FORM

1. Insured / Applicant Information

Date of Birth:    Policy Number:

2. Current Policy Details

Policy Type:    Coverage Limit:

Deductible:    Annual Premium:

Policy Period: From to

3. Renewal Coverage Options

Select coverages to be continued or added upon renewal. Check all that apply. Checked items will be subject to applicable premium adjustments and endorsements.

Liability Coverage
Comprehensive Coverage
Collision Coverage
Personal Accident Coverage
Property Damage Coverage
Additional Endorsements (describe)

4. Material Changes & Risk Questions

Answer the following questions. A "Yes" response may require additional underwriting review and may affect renewal terms or coverage availability.

Have there been any changes in occupancy, use, or operations at the insured premises since the last policy period?    Yes    No

Has there been any loss, incident, claim, or potential claim during the current policy period not previously reported to the insurer?    Yes    No

Have any drivers, key personnel, or insured parties been added, removed, or had significant changes in status since the last policy?    Yes    No

5. Premium, Payment & Billing Instructions

Renewal Premium Due:    Payment Frequency:

6. Beneficiary Designation (If applicable)

Complete only if the policy provides a payable benefit to a named beneficiary.

7. Policy Exclusions & Endorsements

The following exclusions or endorsements may be applied to the renewal. Check if acknowledged and accepted. A check indicates your acknowledgement that the exclusion/endorsement may be applied, subject to underwriting and premium adjustment.

Wear and Tear Exclusion
War and Terrorism Exclusion
Pollution Exclusion
Named Driver Endorsement

8. Certification and Authorization

By signing below, the applicant certifies that the information provided on this renewal form is true, complete, and correct to the best of the applicant's knowledge. The applicant understands that incomplete or inaccurate statements may result in denial of coverage, denial of claims, or rescission of the policy in accordance with the terms of the policy and applicable law.

The applicant authorizes the insurer and its representatives to obtain and verify information necessary to underwrite and renew this policy, including but not limited to claims history, credit information (if applicable), inspection reports, and other underwriting data. The applicant agrees to promptly provide any requested documentation in support of statements made herein.

The insurer reserves the right to amend renewal terms, premiums, effective dates, and coverage by issuing an endorsement or nonrenewal notice in accordance with policy provisions and applicable law.

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