Insurance Policy Safeco Documents

INSURANCE POLICY SAFECO DOCUMENTS

Policy and Insured Identification

Policy Number:    Insured Name:

Date of Birth (if individual):    Tax ID / SSN (last 4):

Individual    Corporation    LLC    Trust    Other:

Policy Details

Policy Type:    Coverage Limit: $

Annual Premium: $    Payment Frequency:

Policy Period Effective From:    To:

Coverage Selections

General Liability (Limit: $)

Property Coverage (Limit: $)    Deductible: $

Collision Coverage (Limit: $)    Comprehensive Coverage (Limit: $)

Uninsured/Underinsured Motorist    Medical Payments

Optional Endorsements Requested:
Hired/Non-Owned Auto Endorsement    Employee Practices Liability    Cyber Liability    Other:

Exclusions

The following exclusions apply to coverage except where an endorsement expressly provides otherwise. Notwithstanding any other provision, coverage does not apply to claims arising from willful acts, intentional loss, fraudulent misrepresentation, or criminal conduct.

Beneficiary Designation

Primary Beneficiary 1:    Relationship:    %:

Primary Beneficiary 2:    Relationship:    %:

Contingent Beneficiary:

Note: Beneficiary percentages should total 100%. In the absence of valid beneficiary designation, benefits will be paid according to policy terms and applicable law.

Claims Information and Initial Notice

Police Report    Photographs    Receipts/Invoices    Witness Statements    Repair Estimates    Other:

Declarations, Terms and Certifications

The undersigned certifies that the information contained in this document and any attachments is true, complete, and correct to the best of the insured's knowledge. The insured acknowledges and agrees that material misrepresentation, concealment, or omission of fact may render the policy voidable at the insurer's option and may subject the insured to denial of claims and rescission of coverage to the extent permitted by law.

Premiums are due as set forth in the policy. Failure to pay premium when due may result in cancellation in accordance with policy provisions. The insured authorizes Safeco and its representatives to obtain and verify information pertinent to underwriting, rating, claims handling, and premium collection, and to exchange such information with claimants, reinsurers, and other insurers when necessary to administer the policy.

Subrogation: To the extent the insurer pays a claim, the insurer shall be subrogated to the insured's rights against any person or entity causing or contributing to loss. The insured shall execute reasonable documents and cooperate with the insurer in pursuing subrogation.

Arbitration: Except where prohibited by law, any dispute arising out of or relating to this policy shall be resolved by binding arbitration in accordance with the policy's arbitration provision. Agreement to arbitrate is a condition of coverage and survives termination of the policy.

Cancellation and Nonrenewal: This policy may be canceled or nonrenewed in accordance with the express terms of the policy and applicable law. Notice requirements and any return premium calculation will follow policy provisions.

I acknowledge receipt of the policy declarations and related Safeco documents.
Premium is financed by a third party or finance agreement.
I consent to assignment and subrogation actions as necessary under the policy.

Producer / Agency Information

Agent License #:    Contact Phone:

Additional Remarks / Endorsements Requested

Certification and Signature

I certify the statements and representations in this document and any attachments are complete and accurate. I agree that this document, together with the policy declarations and endorsements, constitute the agreement between the insured and Safeco as to the coverages and terms referenced herein. I understand that falsification or omission of material facts may result in denial of coverage and other remedies provided by law.

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