Insurance Policy Submission Information Checklist

Insurance Policy Submission Information Checklist

Applicant / Insured Information

Date of Birth: Phone: Email:

Policy & Coverage Details

Proposed Policy Type: General Liability Property Commercial Auto Professional/Errors & Omissions

Estimated Annual Premium: Proposed Policy Period From: To:

Coverage Options / Additional Insureds

Coverage Add-Ons (select all applicable):
Additional Insured Endorsement Waiver of Subrogation Primary & Noncontributory Cyber/Privacy Liability

Required Submission Documents (check when included)

Completed & signed application
Signed underwriting supplemental forms
Prior carrier loss runs (minimum 3–5 years)
Most recent financial statements / tax returns (if required)
Property schedule / valuation
Vehicle schedule (year, make, VIN) for auto submissions
Resumes, professional licenses, or certifications
Photos, site plans, or layouts (if applicable)
Bank account documentation for EFT premium collection
Proof of identity / entity formation documents

Loss History / Prior Carrier Information

No, none to report Yes — loss runs and explanations attached

Beneficiary / Payee Information

Primary Payee Name:

Relationship to Insured: Percentage of Proceeds:

Exclusions and Special Conditions

The undersigned acknowledges that standard policy forms contain exclusions, limitations, and conditions that may apply to the coverage requested. Attachments identifying requested endorsements or exclusions must be provided for underwriting review. The insurer may require revised limits, additional exclusions, or special conditions as a condition of bindable coverage.

Applicant acknowledges receipt and review of the exclusion summary provided and understands that submission does not itself bind coverage.

Declaration and Authorization

By signing below, Applicant certifies that the information provided on this checklist and any attachments is true, complete, and presented in good faith. Applicant understands that material misrepresentation, concealment, or omission of information may be grounds for policy declination, cancellation, or rescission in accordance with the terms of any issued policy.

Applicant authorizes the insurer and its representatives to obtain and verify underwriting information, loss history, financial information, and any other information necessary to evaluate this submission. This authorization extends to prior insurers, credit agencies, and other parties who may furnish such information.

Applicant further acknowledges that completion of this checklist is for underwriting evaluation only and does not constitute an agreement to bind coverage. Coverage will be bound only upon issuance of a policy or binder signed by an authorized representative of the insurer.

I declare under penalty of perjury under the laws of the applicable jurisdiction that the foregoing is true and correct to the best of my knowledge.

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