Insurance Regroupment Form

INSURANCE REGROUPMENT FORM

Applicant / Insured Information

Date of Birth:    Contact Phone:    Email:

Policies to Be Regrouped

List current policies to be consolidated under the regroupment. Provide complete policy identifiers and coverage summaries. Attach additional schedules if necessary.

Type:   Coverage Limit:   Deductible:

Policy Period From:   To:

Type:   Coverage Limit:   Deductible:

Policy Period From:   To:

If more policies are to be regrouped, attach a separate schedule entitled "Supplemental Policy Schedule" and indicate the total number of attached pages below.

Regroupment Details

Requested Effective Date of Regroupment:

Coverage & Endorsements

Select coverages to be included in the regrouped master policy. Unchecked coverages will not be assumed unless otherwise agreed in writing.

General Liability (GL)    Property    Commercial Auto

Workers' Compensation    Professional Liability (E&O)    Cyber Liability

Premium Allocation & Payment Instructions

Indicate how future premiums and commissions are to be allocated and paid following regroupment. If installments are to be used, indicate responsible party.

Applicant / Insured responsible    Third-party payer (specify below)

Exclusions & Special Conditions

The regroupment will be subject to the following exclusions and special conditions. Applicant acknowledges that any pre-existing exclusions, endorsements, or warranty breaches included on the listed policies will continue to apply to the regrouped coverage unless explicitly removed in writing by the carrier.

Applicant acknowledges pre-existing exclusions remain effective unless expressly removed.

Beneficiary Designation (if applicable)

Provide beneficiary information for proceeds where permitted by policy contract.

Relationship:   Share Percentage:

Relationship:   Share Percentage:

Claims History & Documentation Checklist

Has the Applicant reported any losses in the last five years related to the listed policies?    Yes    No

Documentation required to process regroupment (check items included):

Current Declarations Page(s)    Loss Runs (last 5 years)    Proof of Premium Payment

Power of Attorney / Authorization (if third-party acting)    Other (describe below)

Declarations, Representations and Authorization

By signing below, the Applicant certifies and represents that: (a) all information provided in this form and any attachments is true, complete, and accurate to the best of the Applicant's knowledge; (b) the Applicant authorizes the insurers, brokers, or administrators identified herein to effect the regroupment of policies as requested and to exchange underwriting, claims and premium information among them for the purpose of implementing and administering the regroupment; (c) the Applicant acknowledges that regroupment may result in changes to premium, coverage terms, endorsements and deductibles, and that no change is effective until accepted in writing by the insurer(s); and (d) the Applicant will notify the insurer(s) immediately of any material change in risk or circumstance affecting coverage.

Applicant further understands and agrees that carriers retain sole discretion to accept or deny any regroupment request and that any premium adjustments, retrospective audits, or mid-term endorsements required to effect the regroupment will be charged as specified in the applicable policy language or as otherwise agreed in writing.

The Applicant authorizes representatives of the insurer(s) and their authorized agents to obtain and disclose information reasonably necessary to evaluate and administer the regroupment, including prior claim history and loss information. Applicant acknowledges that information provided herein may be relied upon by the insurer(s) in underwriting and pricing decisions.

I certify under penalty of perjury that the foregoing statements and answers are true and complete. I understand that any material misrepresentation or omission may result in denial of coverage, rescission, or other lawful remedies.

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