Insurance Policy Renewal Questionnaire

INSURANCE POLICY RENEWAL QUESTIONNAIRE

Insured / Applicant Information

Insured Name:

Policy Details

Policy Number:     Policy Type:

Current Policy Period: From to

Coverage Selection and Changes

Please indicate the coverages to be continued, added, or removed for the renewal period:

Property (Building & Contents)    General Liability    Business Interruption

Commercial Auto    Cyber Liability    Flood    Earthquake

Exclusions & Limitations Acknowledgment

The insured certifies awareness that standard policy exclusions may apply, including but not limited to: wear and tear, gradual deterioration, deliberate acts, pollution not specifically endorsed, war and nuclear hazard, and losses excluded by endorsement. Any requested extension of coverage must be documented and agreed by the insurer as an endorsement to the policy.

I acknowledge I have read and understand the standard exclusions and limitations that may apply to the renewed policy:   

Claims History (Most Recent Policy Period and Prior 3 Years)

Have there been any claims, incidents, losses, or notices of potential claim during the policy period or prior three years?    Yes    No

If Yes, provide details for each claim below (attach additional pages if necessary):

Risk Management / Changes Since Last Policy Inception

Have there been any material changes to operations, occupancy, security, fire protection, or property condition since the last effective date?

Yes    No

Business Details (If Applicable)

Beneficiary / Payee Information (If Applicable)

Complete beneficiary information only when applicable to the policy type (life, fidelity, certain endorsements).

Documentation Checklist (Attach as Applicable)

Please indicate documents attached with this renewal questionnaire:

Photographs of property / damaged items    Repair invoices / estimates    Police / incident reports

Inspection or engineering reports    Other (describe below)

Declaration and Authorization

I certify that the information provided in this Insurance Policy Renewal Questionnaire is true, complete and accurate to the best of my knowledge. I understand that this information will be relied upon by the insurer in determining underwriting acceptability and premium for the policy renewal. I acknowledge that any material misrepresentation, omission, or failure to disclose may result in denial of coverage, rescission of the policy, or adjustment to terms and premium.

I authorize the insurer and its representatives to make or obtain inspections, investigations, and to obtain loss history and claims information from prior insurers, agents, and other third parties as necessary for underwriting and renewal of coverage. I understand that the insurer may retain copies of documents submitted with this questionnaire.

By signing below I confirm that I have read and understand the statements above and that I have the authority to bind the insured to this declaration.

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