Insurance Quote and Waiver

Insurance Quote and Waiver

Applicant Name:    Insurer Name:

Quote Number:    Date of Quote:

Applicant / Insured Information

Policy Details (Estimate)

Policy Type: Auto Homeowners Renters General Liability Professional Liability Commercial Property Other:

Policy Period (Proposed): From to

Coverage Options

Select optional endorsements or coverages to be included in the quote:

Additional Living Expenses (ALE)
Collision
Comprehensive / Other Than Collision
Umbrella Liability
Employment Practices Liability (EPLI)
Bodily Injury Liability
Specify other endorsement:

Exclusions

The following are examples of standard exclusions and limitations that apply unless expressly added by endorsement: intentional or criminal acts by the insured, wear and tear, inherent vice, war or nuclear events, pollution or contamination except where coverage is specifically purchased, business pursuits not disclosed to the insurer, and losses arising from fraudulent misrepresentation. This list is illustrative and not exhaustive; the final policy form governs coverages and exclusions.

I acknowledge that I have read and understand the stated exclusions and limitations as part of this quote.

Beneficiary Designation

Complete beneficiary information below for policies that permit beneficiary designation.

Prior Claims and Loss History

Have you had any insurance claims, losses, or suits in the last five years?    Yes    No

Documentation Checklist

Please indicate documents provided in support of this quote request:

Proof of ownership / title
Photographs of property / vehicle
Loss history / prior policy declarations
Business financials (if commercial)
Other supporting documents

Declaration and Waiver

The undersigned certifies that the information provided in this Insurance Quote and Waiver is true, complete and accurate to the best of the undersigned's knowledge. The undersigned understands that this document is an estimate and a preliminary proposal only and does not constitute a binding insurance policy. Coverage is effective only upon issuance of a written policy and receipt of any required premium by the insurer.

By signing below, the Applicant acknowledges and agrees that: (a) the insurer and agent may rely on the statements in this form in preparing a formal policy; (b) any material misrepresentation or omission may render any eventual policy void or voidable as provided by law and the policy terms; (c) the insurer is authorized to obtain underwriting, claims, credit, and other relevant information from third parties and to share such information with reinsurers and affiliates as necessary to evaluate the risk; and (d) the Applicant expressly waives any claim for coverage or damages arising from reliance on this quote prior to issuance of an enforceable policy, except as otherwise required by law.

The Applicant further agrees to indemnify and hold harmless the insurer and its agents from any claims, costs or expenses arising from false statements or failure to disclose material facts in the application for coverage. Nothing in this waiver limits the Applicant's rights under applicable law where such limitation is prohibited.

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