Insurance Renewal Application

Insurance Renewal Application

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Existing Policy Information

Policy Number:    Insurer Name:

Policy Type:    Current Premium: $

Coverage Limit(s):

Deductible: $    Renewal Effective Date:    Renewal Expiration Date:

Requested Coverage for Renewal

Select coverages to renew or modify (check all applicable):

Property Coverage     Limit: $

Liability Coverage     Limit: $

Collision Coverage     Deductible: $

Comprehensive Coverage     Deductible: $

Medical Payments / Personal Injury Protection     Limit: $

Changes in Risk / Material Facts

Have there been any changes since the last policy period that affect risk? (new drivers, renovations, business use, security systems, etc.)    Yes    No

Claims History (Past 5 Years)

List all claims or losses in the past 5 years. If none, enter "None".

Beneficiary Designation (if applicable)

Designate beneficiary(ies) for proceeds where applicable. Percentages should total 100%.

Documentation Checklist

Please attach or provide the following as part of renewal evaluation:

Recent photos of insured property/vehicle

Proof of security systems / alarms (if installed)

Relevant medical or repair records (for prior claims)

Proof of ownership / valuation (for high-value items)

Exclusions and Important Notices

The policy does not provide coverage for loss or liability arising from: intentional acts or criminal activity by the insured; wear and tear, gradual deterioration, mechanical breakdown not caused by a covered peril; nuclear hazard, war, insurrection or government seizure; and any other exclusion specifically set forth in the policy contract. Renewal is subject to underwriting approval and adherence to all policy conditions.

Fraud Warning: Any person who knowingly presents false information for the purpose of obtaining insurance or renewal may be subject to criminal and civil penalties, including denial of coverage or rescission of the policy.

Authorization and Certification

By signing below, the applicant certifies that all statements made in this application are true and complete to the best of the applicant's knowledge. The applicant authorizes the insurer and its representatives to obtain and verify any information necessary to evaluate this renewal application, including loss history, inspection reports, credit history where permitted by law, and other relevant records. The applicant understands that failure to disclose material facts or submission of false statements may result in denial of coverage or rescission of the policy.

Renewal premium payment obligations, effective dates, and binding of coverage will be provided in the insurer's renewal offer. No coverage will be in force beyond the current policy expiration date unless a binding receipt or endorsement is issued by the insurer or its authorized representative.

Applicant agrees to promptly notify the insurer of any material change in circumstances prior to the renewal effective date. The insurer reserves the right to amend, decline, or condition renewal based on underwriting review.

Acknowledgment

I acknowledge that I have read and understand the statements, exclusions and authorizations contained in this application. I certify that the information provided is accurate and complete.

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