Insurance Protection Program

INSURANCE PROTECTION PROGRAM

Program Enrollment Form — This Insurance Protection Program ("Program") provides coverage subject to the terms, conditions, exclusions and limits set forth in the applicable policy or master contract issued by the insurer. Completion and acceptance of this form does not guarantee coverage until issued and premium is paid in accordance with the policy provisions.

Applicant / Insured Information

Date of birth:

Policy Details

Requested policy type (select all that apply):

Policy period: From to

Coverages & Options

Select optional coverages (selection affects premium and applicability is subject to underwriting):

Exclusions and Limitations

The following are examples of common exclusions; the master policy contains the complete list of exclusions, limitations and conditions. Coverage under this Program will not apply to loss or liability arising from:

1. Intentional acts, criminal acts, or fraudulent conduct by the insured;
2. Wear and tear, gradual deterioration, corrosion, or inherent vice;
3. War, invasion, insurrection, terrorism and nuclear hazard (subject to policy definition);
4. Losses resulting from pollution, contamination, or biological agents except as expressly provided;
5. Contractual liability assumed by the insured except to the extent the insured would have been liable in absence of the contract;
6. Losses related to business pursuits unless commercial coverage is specifically endorsed.

Beneficiary Designation

Designate one or more primary beneficiaries for benefits payable upon a covered accidental death or similar benefit. Percentages must total 100%.

Claims & Documentation (Notice)

In the event of a loss, notify the insurer or program administrator promptly. Provide a description of the incident, date of loss, and an itemized estimate of damage. Failure to provide timely notice or required documentation may result in denial of coverage.

Representations, Certification and Agreement

By signing below I represent and warrant that the information provided on this form is true, complete and accurate to the best of my knowledge. I understand that material misrepresentations or omissions may render coverage void from inception and may be cause for denial of claims or rescission of the policy. I authorize the insurer and its representatives to obtain and verify information necessary to underwrite, issue, and service this Program, including claims history and other insurance records.

I understand that coverage is subject to the policy terms, conditions, endorsements and applicable premium. I agree to pay required premiums when due and acknowledge that failure to pay premium may result in cancellation or non-renewal pursuant to the policy provisions. Any disputes regarding coverage or this enrollment shall be resolved in accordance with the dispute resolution provisions set forth in the issued policy.

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