Insurance PRG Application Form

Insurance PRG Application Form

Applicant / Insured Information

Applicant Name:

Individual Corporation Limited Liability Company Trust

Policy Details

Property Liability PRG (Performance & Return Guarantee) Professional Liability

Proposed Policy Period: From to

Coverage Options & Limits

Select coverage components to be included in the policy. Limits indicated where required.

General Liability — Limit:

Property Damage — Limit:

Business Interruption — Indemnity Period:

PRG Specific Coverage — Guaranteed Obligation Limit:

Exclusions and Conditions

The policy will contain standard exclusions including, but not limited to: intentional acts or fraud, war and acts of sovereign authority, pollution unless specified, known and pending claims at inception, and contractual liability except to the extent the Insured would have been liable in the absence of such contract. Applicant acknowledges that additional exclusions may be applied by endorsement and that coverage is conditioned on truthfulness of representations herein.

Applicant acknowledges receipt of and agreement to the potential application of specific endorsements or requirements based on underwriting review, including additional deductibles, co-insurance provisions, and sublimits. Applicant must initial to indicate review:

Beneficiary Designation

If applicable, designate a beneficiary for proceeds or recoveries under this policy:

Prior Insurance & Loss History

Has the applicant had any claims, losses, or suits in the past five (5) years? Yes No

Documentation Checklist

Please include the following documents with this application (check included items):

Copy of Government ID for Applicant

Most Recent Financial Statements

Prior Policy Declarations / Loss Runs

Relevant Contracts / Guarantees to be Insured

Declarations, Authorization and Certification

The undersigned declares that the information provided in this application is true, complete and accurate to the best of the undersigned's knowledge and belief. The undersigned understands that any intentional misrepresentation or omission of material fact may result in denial of coverage and may be grounds for rescission of coverage.

The undersigned authorizes the insurer, its agents and representatives to obtain and verify information pertaining to the applicant, including claims history, financial information, and other underwriting data from prior insurers, financial institutions, and credit reporting agencies as necessary to underwrite and administer the policy. The undersigned further authorizes release of claim and underwriting information to third parties with an insurable interest where required.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application containing materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, may be subject to civil and criminal penalties under applicable law.

Authorization for Payment & Premium Terms

By submitting this application the applicant acknowledges that coverage is not binding until accepted and a policy issued by the insurer. Applicant agrees to remit premium as specified in the policy and acknowledges that late payment may result in cancellation or lapse of coverage. The insurer reserves the right to require additional information, inspections, or amendments to the application as a condition of binding coverage.

ACH / Bank Transfer Check Credit Card

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