Insurance Policy to Sign

INSURANCE POLICY

Policy Number:     Producer:     Effective Date:

Insured Information

Date of Birth:     Phone:     Email:

Policy Details

Policy Type: Homeowners Auto Commercial General Liability Umbrella

Deductible:     Annual Premium:     Payment Frequency: Annual Monthly

Policy Period Start:     End:

Coverages Selected

Liability Coverage
Property Damage Coverage
Collision (if applicable)
Comprehensive (if applicable)
Medical Payments
Uninsured/Underinsured Motorist
Business Interruption
Cyber Liability

If specific limits differ from the overall Coverage Limit, list them here:

Exclusions and Conditions

The coverage provided by this policy is subject to the terms, conditions, limitations and exclusions contained herein. Standard exclusions include but are not limited to: fraudulent acts or intentional loss by the insured; wear and tear, gradual deterioration, rust, corrosion; nuclear hazard; war, insurrection, and governmental action; damage arising from professional services where a professional liability endorsement is not purchased; loss attributable to pollution except as expressly provided by endorsement; and losses excluded by any applicable endorsement. Coverage applies only to losses that are fortuitous, accidental, and reported in accordance with the Claims Notification provision below.

Subrogation: By acceptance of this policy, the insured assigns to the insurer the right to recover from third parties to the extent of payments made by the insurer. The insured shall cooperate fully with the insurer and shall not prejudice the insurer's subrogation rights.

Non-Waiver and Severability: No action or failure to act by the insurer shall constitute a waiver of any right under this policy unless expressly agreed to in writing. If any provision of this policy is held invalid, the remainder shall continue in full force.

Acknowledgement: I acknowledge that I have read and understand the Exclusions and Conditions and that coverage is limited to the terms stated in this policy.

Beneficiary Designation

Primary Beneficiary Name:     Relationship:     Percentage:

Contingent Beneficiary Name:     Relationship:     Percentage:

Claims Notification and Duties of Insured

Notice of Loss: The insured must provide written notice to the insurer as soon as reasonably practicable, but no later than thirty (30) days from discovery of loss unless a longer period is required by law. The notice must include the date, cause and description of the loss, and the amount claimed to the extent known.

Duties Following Loss: The insured shall take reasonable steps to protect covered property from further damage, provide access to the insurer for inspection, submit proofs of loss, and cooperate in the investigation and settlement of any claim. Failure to comply with these duties may result in denial of coverage to the extent the insurer is prejudiced.

Cancellation and Renewal

Cancellation: This policy may be cancelled by the insured at any time upon written notice. The insurer may cancel for nonpayment of premium or for other reasons as permitted by the policy and applicable law; notice requirements in the policy and applicable statutes shall control. Refunds, if any, shall be computed in accordance with the insurer's customary short-rate or pro rata basis as applicable.

Renewal: Renewal is subject to the insurer's underwriting guidelines and payment of the required premium. Nothing in this policy obligates the insurer to renew beyond the policy period.

Declarations and Certification

By signing below, the insured certifies that all statements and representations contained in this application and any attachments are true, complete and accurate to the best of the insured's knowledge. The insured understands that material misrepresentation or omission may constitute grounds for denial of coverage or rescission of the policy. The insured authorizes the insurer to obtain and verify personal or business information relevant to underwriting and claims, and to share such information with reinsurers and contractors as necessary for policy administration. The insured further acknowledges receipt of the policy terms and accepts the policy subject to its stated provisions, exclusions, and conditions.

Fraud Warning: Any person who knowingly and with intent to defraud submits an application or claim containing false, incomplete or misleading information may be guilty of insurance fraud and subject to civil and criminal penalties.

Arbitration and Dispute Resolution: Except where prohibited by law, disputes arising under this policy shall be resolved through binding arbitration in accordance with the arbitration clause contained within the policy. Election to pursue arbitration does not affect the insured's duty to cooperate with claim handling.

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