Insurance Policy Rewrite

INSURANCE POLICY REWRITE

Client Name:   Insured Entity (if different):

Original Policy Number:   Original Effective Date:

Requested Rewrite Effective Date:   Requested By (Agent/Broker):

Applicant / Insured Information

Policy Details - Current and Requested

Current Policy Type:

Current Coverage Limit: $   Current Deductible: $

Requested Coverage Limit: $   Requested Deductible: $

Current Annual Premium: $   Estimated Revised Premium: $

Current Policy Period From:   To:

Coverage Selection / Options

The applicant requests the following coverage types to be added, increased, decreased, or retained. Check all that apply and specify requested limits where applicable.

General Liability   Limit: $

Property   Limit: $

Auto (Liability & Physical Damage)   Limit: $

Professional Liability / E&O   Limit: $

Umbrella / Excess   Limit: $

Exclusions and Endorsements

The rewrite may add, remove, or modify policy exclusions and endorsements. List exclusions to be added or retained and endorsements to be issued below. If none, state "None".

Reason for Rewrite & Loss History

Premium Adjustment & Payment

Anticipated Additional Premium Due: $   Refund Due to Insured: $

Beneficiary Designation (if applicable)

Beneficiary Name:   Relationship:

Percentage of Benefit: %    Contingent

Alternate Beneficiary Name:   Relationship:

Percentage of Benefit: %

Agent / Broker Information

Declarations & Certification

I, the undersigned applicant or authorized representative, request the insurer to rewrite the policy identified above in accordance with the changes set forth in this form. I certify that all statements and representations contained in this request are true, complete and material to the risk and to the insurer's determination whether to provide the coverage requested. I understand that the insurer may rely on these statements in effecting the rewrite and that any material misstatement or omission may render the policy voidable or subject to amendment.

By signing below I authorize the insurer to: (a) effect the requested endorsement(s) or policy change as set forth herein; (b) adjust premiums, fees, and effective dates as required; and (c) obtain and use underwriting, claims, and loss history as necessary to evaluate and issue the rewritten policy. I acknowledge that coverage changes may impose new exclusions, limitations, or conditions and that the insurer's acceptance of this request may be subject to approval and underwriting review.

Applicant further authorizes the agent/broker identified above to act as my agent in connection with this rewrite request, including receipt of notices, endorsements, and billing statements unless otherwise revoked in writing.

I certify under penalty of perjury that the information provided in this Insurance Policy Rewrite form is true and correct to the best of my knowledge.

Attachments & Documentation

Attach copies of relevant documents to support this rewrite request. Check items attached:

Loss runs (past 5 years)

Updated application or supplemental information

Photographs, inspection reports, or supporting documents

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