Insurance Remarketing Application

INSURANCE REMARKETING APPLICATION

Applicant Name:

Producer / Broker:    Producer License #:

Applicant / Insured Information

Individual    Corporation    LLC    Partnership    Other:

Date of Birth (if individual):    State of Domicile:

Policy Details — Current/Target

Desired Remarketing Effective Date:    Desired Term (months):

Coverage Requested

Indicate coverage lines to be marketed (check all that apply):

Commercial General Liability    Commercial Auto    Property    Workers' Compensation    Professional Liability    Umbrella/Excess

Exclusions, Limitations and Known Issues

Does the current policy contain any non-standard exclusions, punitive damage carve-outs, or warranty conditions?    Yes    No

Claims and Loss History

Have there been any claims, suits, or incidents reported in the last five (5) years?    Yes    No

Itemize up to three (3) most recent claims

Loss runs for the requested period are: Attached    Not Available

Beneficiary Designation

(Complete only if remarketing involves life, disability, or similar benefits)

Attachments and Documentation

Please indicate which documents are submitted with this application (check all that apply):

Policy Declarations Page(s)    Full Policy Wordings    Loss Runs (last 5 years)

Photographs / Site Reports    Premium Audit Reports    Other:

Declarations, Authorizations and Certifications

By signing below, the Applicant certifies that all statements and information contained in this application and in any attachments are true, complete and correctly recorded to the best of the Applicant's knowledge. The Applicant understands that this application is a material inducement to any insurer deciding whether to provide quotations or to bind coverage and that insurers will rely upon the truthfulness of the representations contained herein.

The Applicant authorizes current and prior insurers, claims administrators, and third parties to release claim history, underwriting files and any other information necessary for the remarketing of the policy, including loss runs and claim documentation. The Applicant acknowledges that submission of this application for remarketing does not in itself bind coverage and that no coverage will be effective unless and until accepted and issued by a carrier and the required premium is received by that carrier.

The Applicant agrees to notify the broker promptly of any material change in operations, exposures, or claims activity between the date of this application and the effective date of any replacement policy. The Applicant understands that failure to disclose material information may result in declination, rescission, or voidance of coverage and/or reimbursement obligations for any premium paid.

Fraud Warning: Any person who knowingly provides false, incomplete, or misleading information with intent to defraud may be subject to civil or criminal penalties under applicable law, and such conduct may void coverage.

Signature and Authorization

The undersigned affirms that they are authorized to execute this application on behalf of the Applicant and that the statements contained herein are true and complete. Signing this form constitutes an authorization for the broker and prospective insurers to obtain and exchange underwriting and claims information as necessary to effect remarketing.

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