Insurance Rating Info

INSURANCE RATING INFO

Applicant / Insured Information

Client Name:

Date of Birth:

Policy Details

Policy Number:

Policy Effective:    Policy Expiration:

Homeowners Dwelling Fire Commercial Property Auto General Liability Workers' Comp Umbrella Professional Liability

Exposure & Rating Factors

Discounts and Surcharges

Protective devices (alarms/sprinklers) Multi-policy discount Prior loss-free credit Automatic sprinkler credit Security system credit

Surcharges applicable: High-risk occupancy Recent prior losses Inadequate fire protection

Exclusions

Standard exclusions, endorsements, and limitations may apply. The insurer's policy will control coverage. The following exclusion specifics or unusual exposures should be noted below and will be considered in the final rate and form selection.

Supporting Documentation Checklist

Current declarations page Loss runs (past 5 years) Recent photos of property or vehicle Appraisal or valuation Blueprints / building plans Payroll / receipts (if applicable for workers' comp)

Beneficiary Designation (if applicable)

Beneficiary 1 Name:

Relationship:    Percentage:

Beneficiary 2 Name:

Relationship:    Percentage:

Beneficiary 3 Name:

Relationship:    Percentage:

Rating Calculation Summary

Underwriting Remarks

Declaration and Authorization

I certify that the information provided on this Insurance Rating Info form is true and complete to the best of my knowledge. I understand that this information will be relied upon by the insurer for underwriting and premium calculation purposes and that any material misrepresentation or omission may result in policy denial, rescission, or adjustment of premium and coverage terms. I authorize the insurer and its authorized representatives to obtain and verify loss history, prior coverage, credit information (when applicable to rating), and to inspect the property or exposures identified herein. I acknowledge that the figures provided are estimates and the final premium, coverage scope, and applicable endorsements will be set forth in the insurer's policy documentation.

I further certify that I will furnish all supporting documentation requested by the insurer in a timely manner, including declarations pages, loss runs, appraisals, and photographs. Failure to provide requested documents may delay issuance and may result in adjusted rating based on available information.

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