Insurance Policy Suspension

INSURANCE POLICY SUSPENSION

This Insurance Policy Suspension Request and Agreement is submitted to the Insurer for temporary suspension of coverage under the policy identified below. The undersigned certifies that the information provided is true and complete and requests suspension in accordance with the terms set forth herein.

Policy Identification

Insurer Name:

Policy Number:    Policy Type:

Insured / Applicant Information

Policy Details

Coverage Limit(s):

Deductible:    Current Annual Premium:

Policy Period From:    To:

Requested Suspension — Coverage Selection

I request suspension of the following coverage components (check all that apply):

Suspend Entire Policy

Liability Coverage

Collision Coverage

Comprehensive Coverage

Uninsured / Underinsured Motorist

Personal Injury Protection (PIP)

Medical Payments

Other (describe):

Suspension Period & Reason

Requested Suspension Effective Date:    Anticipated Reinstatement Date:

Vehicle or property in storage / non-use

Temporary financial hardship

Transfer of possession / loaner arrangement

Other (explain below)

Premium Adjustment, Fees & Refunds

Method of premium adjustment (check one): Prorated refund Policy credit toward future premium No refund / no credit

Administrative suspension fee (if applicable):

Obligations During Suspension

By requesting suspension, the Insured acknowledges and agrees to the following obligations and conditions during the suspension period:

1. No use or operation: The insured property will not be operated, driven, or made available for hire if coverage for such use is suspended.

2. Storage and security: Vehicles or property must be stored and secured in accordance with the Insurer's specified requirements; failure to do so may void the suspension and any refund.

3. Duty to notify: The Insured shall notify the Insurer immediately of any change in circumstances that would affect the suspension, including sale, transfer, or reinstatement of use.

4. Claims during suspension: Coverage for claims arising from uses expressly excluded by this suspension will be denied; the Insurer shall have no liability for losses occurring during the suspended period except as specifically agreed in writing.

Exclusions and Limitations

Suspension does not affect coverage for obligations or losses that the policy expressly continues to cover. The following are examples of standard exclusions applicable to suspensions:

- Intentional acts or fraud by the Insured.

- Liability arising from operation or use of the insured property during the suspension period where operation was prohibited.

- Any obligations to third parties arising from contracts or statutory requirements that survive suspension of insurance.

Beneficiary Information (If Applicable)

Provide beneficiary details only if this suspension request relates to a policy that names beneficiaries (e.g., life, disability). If not applicable, leave blank.

Relationship:    Percentage:

Relationship:    Percentage:

Certification and Acknowledgment

By signing below, the Applicant/Insured certifies that all statements in this request are true and complete to the best of their knowledge and agrees that the Insurer may rely upon this request in effecting suspension of coverage. The Applicant further acknowledges that suspension may result in reduced or forfeited benefits, administrative fees, and that reinstatement requirements may include proof of storage, inspection, or payment of outstanding premiums and fees.

The Applicant understands that any misrepresentation or failure to disclose material facts may result in denial of refund, rescission of suspension, or cancellation of the policy in accordance with the policy terms and applicable law.

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