Insurance Proposal Quote

INSURANCE PROPOSAL QUOTE

Proposal Identification

Proposal Number:

Quote Prepared By (Broker/Agent):

Applicant / Insured Information

Policy Details / Quote Summary

Policy Type:

Payment Frequency: Monthly Quarterly Annual One-time

Quote Valid Until:

Coverage Options

Property (Buildings & Contents) Limit:

General Liability Each Occurrence:

Business Interruption Indemnity Period: Limit:

Owned/Non-Owned Auto Combined Single Limit:

Employers' Liability / Workers' Compensation Limit:

Exclusions (Summary)

This proposal is subject to the insurer's standard policy exclusions, including but not limited to: war and hostilities; nuclear hazard; intentional acts by an insured; wear, tear and gradual deterioration; loss resulting from dishonest or fraudulent acts not covered unless specifically endorsed. The precise exclusions that will apply are set out in the policy wording to be issued upon binding of coverage.

I acknowledge that I have read and reviewed the summary exclusions above and that the full policy wording contains detailed exclusions and definitions. Initials:

Beneficiary / Payee Designation

Complete if policy includes life or benefit payments.

Underwriting Conditions & Documentation

The following documentation is required to complete underwriting. Coverage cannot be bound until items marked with an asterisk are received and reviewed.

Completed Application Form
Latest Financial Statements
Loss History / Claims Runs (past 5 years)
Asset Valuations / Inventory Schedule
Additional Supporting Documents

Declaration and Certification

By signing below, the Applicant certifies that all statements and particulars contained in this proposal are true, complete and accurate to the best of the Applicant's knowledge and belief. The Applicant acknowledges that any material misrepresentation or omission may entitle the insurer to avoid the policy, decline a claim or treat the policy as voidable in accordance with applicable law and the terms of the policy.

The Applicant understands that this document is a quotation and summary of proposed coverage only. Coverage, terms, limits and exclusions are subject to final underwriting, acceptance by the insurer and issuance of a formal policy document. Premiums are due in accordance with payment terms agreed and coverage will not be effective until premium and any required fees have been paid and the insurer has provided binding confirmation.

Acceptance of Quote:

Agreement Acknowledgement

The Applicant authorizes the broker or insurer to obtain such information as may be necessary for underwriting, including claims history and credit-related information where permitted by law. The Applicant agrees to notify the broker promptly of any material change in the risk between the date of this proposal and the inception date of any policy issued.

Applicant Authorization Signature below constitutes a binding representation that the Applicant has authority to enter into this proposal and to provide information on behalf of the named insured.

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