Insurance Protection Plan Application

INSURANCE PROTECTION PLAN APPLICATION

Please complete all sections of this application. Incomplete or inaccurate information may delay processing. By signing this application, Applicant certifies that all information provided is true, complete and material to the acceptance of risk and formation of the insurance contract.

Applicant / Insured Information

Date of Birth:

Policy Details

Select desired plan type (check all that apply):

Policy Period: From to

Coverage Options & Limits

Select additional coverages and specify any requested per-item limits where applicable.

Exclusions

The following are representative exclusions. Coverage is subject to the full policy terms, conditions, and exclusions contained in the issued policy. Applicant acknowledges that losses arising from the following are typically excluded unless expressly scheduled:

1. Losses caused by intentional, fraudulent or criminal acts by the Insured. 2. Wear, tear, gradual deterioration, inherent vice, or mechanical breakdown unless a specific accidental damage rider is purchased. 3. Loss or damage resulting from war, hostilities, riot, nuclear hazard, or government seizure. 4. Losses resulting from failure to maintain reasonable care or to follow manufacturer's instructions. 5. Pre-existing damage or conditions known prior to the effective date unless declared and accepted by the Company.

Beneficiary Designation

Designate one or more beneficiaries who shall receive benefit proceeds subject to policy terms. Percentages must total 100%.

Prior Claims / Loss History

Has Applicant had any insurance claims, losses, or losses denied in the past five (5) years?

Declarations and Authorizations

By signing this application, Applicant represents and warrants that the information provided in this application and any attached schedules is true and complete. Applicant acknowledges that any material misrepresentation, omission or concealment of a fact may render coverage voidable from inception or give the insurer grounds for denial of coverage and/or recovery of paid benefits.

Applicant authorizes the insurer and its authorized representatives to inspect property, obtain and verify information from third parties, including prior insurers, service providers, and repair facilities, and to obtain consumer reports and loss history. Applicant authorizes release of claim and underwriting information where necessary to evaluate this application.

Applicant understands that coverage under the policy shall become effective only upon acceptance and issuance of the policy by the Company and payment of any required premium. Applicant further acknowledges the Company may cancel or rescind coverage in accordance with policy terms and applicable law.

Additional Information / Comments

Applicant Certification

I, the undersigned Applicant, declare under penalty of law that the information provided on this application is true, correct and complete to the best of my knowledge. I understand that acceptance of this application is subject to approval by the insurer and that any false statement may be a basis for denial of coverage or rescission.

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