Insurance Property Renewal Form

Insurance Property Renewal Form

Policy and Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period From to    Renewal Effective Date:

Coverage Selected

Building (Dwelling/Structure)    Contents / Personal Property    Liability    Business Interruption

Ordinance or Law Coverage    Flood (subject to endorsement)    Earthquake (subject to endorsement)    Equipment Breakdown

Material Changes & Property Information

Have there been any material changes to the property or its occupancy since the prior policy period?   Yes    No

Monitored Alarm    Sprinkler System    Fire Extinguishers    Security Guard    None of the above

Claims History

Any claims, losses, or incidents during the prior policy period or since the last renewal?   Yes    No

Claim 1 Date:    Type:    Estimated Amount: $

Claim 2 Date:    Type:    Estimated Amount: $

Claim 3 Date:    Type:    Estimated Amount: $

Loss Payee / Beneficiary Information

Relationship to Insured:    Payment %:

Exclusions and Acknowledgments

The renewal of this policy is subject to the terms, endorsements and exclusions of the policy form. Typical exclusions include but are not limited to loss caused by wear and tear, gradual deterioration, inherent vice, intentional acts by the insured, war, nuclear hazard, and losses excluded by specific endorsements. This renewal does not reinstate coverage for perils specifically excluded by endorsement.

I acknowledge that I have read and understand the exclusions, terms, and conditions referenced above and that coverage is governed by the policy language and endorsements in force at the time of loss.

Documentation Checklist

Please attach current documentation as applicable:

Recent Photographs of Property    Updated Inventory / Contents List    Contractor Invoices / Repair Estimates

Proof of Ownership    Building Permits / Certificates    Other:

Declaration and Certification

By signing below, the undersigned certifies that the information provided in this renewal form is true, accurate and complete to the best of their knowledge. The insured warrants that all material facts affecting the risk have been disclosed. Any material misrepresentation, omission or concealment of fact may constitute a breach of warranty and may result in rescission of coverage or denial of claims to the extent permitted by applicable law.

The insured authorizes the insurer and its representatives to inspect the property, obtain records and request information necessary for underwriting and claims handling. Renewal of coverage is subject to payment of the required premium, satisfactory underwriting review, and any endorsements or conditions applied by the insurer. Acceptance of this renewal form by the insurer does not alter or expand coverage beyond the terms and conditions of the policy forms and endorsements that are issued.

Fraud Warning: It is unlawful to knowingly submit false information or omit material information for the purpose of obtaining insurance proceeds. Such acts may be punishable by civil and criminal penalties.

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