Insurance Quote and Acords

Insurance Quote and Acords

Applicant / Insured Information

Entity Type: Individual Corporation LLC Partnership Trust Other

Phone:    Email:

Date of Birth:    Tax ID / SSN:

Policy Details — Quote Summary

Policy Type:

Estimated Annual Premium:

Policy Period From:    To:

Coverages Requested

General Liability Limit:

Property Limit:

Business Interruption Limit:

Commercial Auto Limit:

Workers' Compensation

Cyber Liability Limit:

Exclusions — Important Notice

The quote set forth herein is subject to underwriting review and standard policy exclusions including but not limited to: intentional acts, professional liability (unless expressly included), wear and tear, hostile acts where excluded by endorsement, pollution unless endorsed, and losses arising from dishonest acts not reported in accordance with policy provisions. Coverage is only effective when binding authority is confirmed in writing by the insurer.

Applicant acknowledges review of standard exclusions and understands exclusions may limit recovery.    Initials:

Beneficiary Information (If applicable)

Relationship:    Percentage:

Relationship:    Percentage:

Prior Loss History / Claims

Have there been any claims or losses in the last 5 years? Yes No

Documentation Checklist

Completed Application

Loss Runs (last 5 years)

Photos / Inspection Reports

Police Report (if applicable)

Agent / Broker Information

Agent/Broker Name:    License #:

Agent Phone:    Agent Email:

Declarations and Certification

By signing below, the applicant certifies that the information contained in this Insurance Quote and Acords form is true, complete and accurate to the best of the applicant's knowledge. Applicant acknowledges that the submission of this form is for quoting and underwriting purposes only and does not constitute a binder of coverage. No coverage will be effective unless and until issued by the insurer in writing. The applicant authorizes the insurer and its representatives to obtain underwriting information including loss history, claims records, credit information where permitted by law, and other relevant information necessary to evaluate the risk.

Applicant understands that intentional misrepresentation or omission of material facts may result in denial of coverage, rescission of policy, or other penalties as provided by law and policy terms. Premium estimates provided herein are subject to change pending complete underwriting, inspections, verification of exposures, and receipt of required documentation.

I certify the foregoing and request this quote be provided based on these representations.

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