Insurance Premium Funding Application

INSURANCE PREMIUM FUNDING APPLICATION

Application Date:

Applicant / Insured Information

Individual Corporation LLC Partnership Trust Other:

Policy and Coverage Information

From: To:

Premium and Funding Request

Monthly Quarterly Semi-Annual Annual

Coverage Selection

Please indicate the coverages funded by this application:

General Liability Property Commercial Auto Workers' Compensation Professional Liability

Documentation Checklist

The following documents should be submitted with this application (check items provided):

Completed Application Copy of Policy / Declaration Page Premium Invoice / Billing Statement Evidence of Down Payment Signed Credit Authorization

Beneficiary / Assignment of Refunds

Applicant elects the following assignment for return premiums and refunds resulting from cancellation or audit:

Exclusions, Limitations and Important Notices

By signing below the Applicant acknowledges and agrees that the premium funding advanced is subject to the following terms and conditions. Applicant represents that all information provided is true and complete and authorizes verification by the Funders of credit, employment and other information. Applicant understands that the funding is not an insurance policy and does not alter the terms of the underlying policy.

Security Interest and Assignment: Applicant grants the Funders a security interest in any rights to return premiums, commissions, dividends, audit adjustments, cancellation refunds or other remittances that may become payable under the policy. Applicant assigns to Funders all such rights until the indebtedness and all other obligations to Funders are paid in full.

Default Remedies: If Applicant fails to make any payment when due, Funders may declare the unpaid balance immediately due and payable, cancel coverage with the insurer, apply any return premium to the indebtedness, and recover reasonable collection costs, attorneys' fees and court costs. Applicant will remain liable for any deficiency after application of refunds and credits.

No Coverage Warranty: Funders do not guarantee coverage under the insured policy; coverage disputes remain between Applicant and Insurer. Funders may require proof of policy issuance prior to final funding and may withhold funding pending insurer confirmation.

Limitations: Funding does not include taxes, statutory fees, or other government-imposed charges unless explicitly included in the funded amount. Applicant remains responsible for any amounts not funded by Funders.

Representations, Authorization and Certification

Applicant certifies, under penalty of perjury, that the information contained in this application is complete, accurate and true. Applicant authorizes Funders to obtain credit reports, background information and to exchange information with insurers and agents for underwriting, servicing and collection purposes. Applicant further authorizes the insurer to disclose policy information, including audits and cancellation notices, to Funders.

Privacy and Credit Authorization

Applicant expressly authorizes any consumer reporting agency or other third party to provide credit or investigative information to Funders and their agents in connection with this application and any subsequent extension, renewal or collection of indebtedness. Applicant acknowledges receipt of any required privacy disclosures and waives receipt of any further preliminary notices except as required by law.

Applicant authorizes credit check and information exchange

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