Insurance Purchase Order Form

INSURANCE PURCHASE ORDER FORM

Order Information

Purchase Order Number:   Order Date:

Requested Effective Date:   Requested Expiration Date:

Applicant / Insured Information

Individual Corporation LLC Partnership Trust

Policy & Coverage Details

Policy Type (select all requested):

Auto Homeowners General Liability Professional Liability Property Life Health Other:

Requested Policy Period: From to

Coverage Options & Endorsements

Select required endorsements and limits where applicable:

Waiver of Subrogation Additional Insured Deductible Buyback Per-incident Aggregate

Exclusions (Standard; applicant must acknowledge)

The following are commonly excluded unless specifically endorsed. Applicant acknowledges these exclusions apply unless otherwise agreed in policy documentation:

• Intentional acts, criminal acts by insured, and deliberate loss.
• War, acts of foreign enemies, and nuclear hazard.
• Wear and tear, gradual deterioration, inherent vice.
• Pollution and contamination except where specifically endorsed.
• Losses covered by other valid and collectible insurance or warranty.

Applicant confirms receipt and review of standard exclusions: Acknowledged

Beneficiary Designation (if applicable)

Complete only for life or similar policies.

Payment & Billing

Payment Method: Check Credit Card ACH / Bank Transfer

If payment by credit card or ACH will be used, applicant authorizes binder premium collection upon binding where permitted by law: Authorization granted

Documentation Checklist

Include the following with this Purchase Order where applicable:

Prior policy declarations Photographs / site condition Completed applications Loss history / claims reports Valuation invoices / proof of value

Declarations and Certifications

The Applicant certifies that the information provided in this Insurance Purchase Order Form is true, complete and accurate to the best of Applicant's knowledge. Applicant understands that issuance of any policy is subject to underwriting review and approval and that coverage will be effective only upon issuance of a policy, certificate, or binder.

Applicant further acknowledges and agrees that: (a) any intentional misrepresentation, omission or concealment of material facts may void coverage and render any policy issued null and void; (b) premiums quoted are estimates and may be adjusted based on underwriting review; (c) the insurer reserves the right to modify terms, conditions, limitations and endorsements prior to issuance; and (d) binding of coverage and delivery of policy documents is subject to receipt of premiums and satisfactory resolution of underwriting requirements.

Applicant authorizes the insurer and its representatives to obtain and exchange loss, claims and underwriting information from prior carriers, claims databases, and other sources as necessary to underwrite and service the policy. Applicant consents to the use of electronic signatures, transmissions and records in connection with this order and any resulting policy.

Signatory Certification

I certify, under penalty of perjury, that I am authorized to submit this Insurance Purchase Order Form on behalf of the Applicant and that the information contained herein is accurate and complete. I understand this document constitutes a request for insurance and does not, in and of itself, bind the insurer until acceptance and issuance of policy documentation by the insurer.

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