Insurance Policy Review of Terms

INSURANCE POLICY REVIEW OF TERMS

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:

Policy Details

Insurer Name:

Policy Number:    Policy Type:

Coverage Amount:    Deductible:    Annual Premium:

Policy Period: From to    Issue Date:

Coverage Summary (Select all that apply)

Property Coverage    Limits:

Liability Coverage    Per Occurrence Limit:

Medical Payments    Limit:

Uninsured/Underinsured Motorist    Limit:

Policy Exclusions and Limitations

The following are principal exclusions or limitations that materially affect coverage. The insured acknowledges these examples and any similarly stated exclusions in the full policy language:

• Wear and tear, gradual deterioration, and maintenance-related loss.
• Intentional acts, fraud, or criminal conduct by insured or additional insureds.
• Certain environmental, pollution, and mold-related losses unless specifically endorsed.
• Losses arising from unlisted business pursuits or professional services absent an endorsement.

I acknowledge I have read and understand the principal exclusions, and I have received the full policy declarations and exclusions pages:

Endorsements and Amendments

Were any endorsements, riders, or amendments issued with this policy?

Beneficiary Designation (if applicable)

Beneficiary Name:

Relationship:    Allocation Percentage:

Claims and Loss Reporting (for policy review)

Have you reported any claims or losses under this policy or prior related policies in the last five years?

Declaration and Certification

By signing below I certify that I have received, reviewed, and understand the policy declarations, coverage summary, exclusions, and any endorsements presented to me. I acknowledge that:

1. The terms, conditions, exclusions, and premium obligations set forth in the policy govern coverage; this Review of Terms is an acknowledgement and does not amend coverage except by written endorsement executed by the insurer.
2. I have had the opportunity to ask questions and have received answers to my reasonable questions concerning the scope of coverage, limits, deductibles, and insured obligations including notice, mitigation, and cooperation requirements in the event of a loss.
3. All facts and statements in this Review and any application supporting the policy are true and complete to the best of my knowledge; material misrepresentations may be basis for denial of coverage or rescission consistent with the policy.

I certify that the information provided above is accurate and complete:

I acknowledge that cancellation, nonrenewal, or premium adjustments will be effected in accordance with the policy language and applicable notice provisions:

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