Insurance Renewal Application Form

INSURANCE RENEWAL APPLICATION FORM

Applicant Name:   Policy Number:

1. APPLICANT / INSURED INFORMATION

2. CURRENT POLICY DETAILS

Auto   Homeowners   Renters   Commercial   Life   Health   Umbrella   Other

Policy Period From:   To:

3. COVERAGE SELECTION / CHANGES

Select coverages to be renewed or added (check applicable):

Liability / Third-Party
Collision
Comprehensive / All Risk
Medical Payments
Personal Property / Contents
Loss of Use / Additional Living Expense
Rental Reimbursement

4. PRIOR CLAIMS / LOSS HISTORY (PAST 5 YEARS)

Complete all claims or enter "None" if no claims.

5. MATERIAL CHANGES AND RISK INFORMATION

Has there been any change in occupancy, use, or risks to the insured property or persons since the last policy was issued?    Yes   No

Are there any new drivers, additional insureds, or occupants to be added to the policy?    Yes   No

6. EXCLUSIONS & ACKNOWLEDGEMENTS

The policy issued upon renewal will be subject to the insurer's standard terms, conditions and exclusions. Typical exclusions include, without limitation, loss arising from: intentional acts; wear and tear or gradual deterioration; war or nuclear hazard; certain high-risk professional activities; and any peril specifically excluded by endorsement. The insurer retains the right to add reasonable endorsements or exclusions based upon underwriting review of the application and claims history.

I acknowledge that I have read and understand the standard exclusions and that any additional exclusions required by the insurer as a condition of renewal will be binding upon issuance of the renewed policy.

Acknowledgement: I acknowledge and accept the stated exclusions and potential endorsement changes.

7. BENEFICIARY / PAYEE INFORMATION (IF APPLICABLE)

8. DECLARATIONS, AUTHORIZATION & CERTIFICATION

I declare that the information provided herein is true, complete and correct to the best of my knowledge and that no material facts have been omitted. I understand that any material misrepresentation, omission or concealment of fact may result in denial of coverage, rescission of the renewed policy, or voidance of coverage from its inception, to the extent permitted by law.

I authorize the insurer, its agents and representatives to obtain and verify information relevant to this application, including prior insurance history, claim records, and other information necessary for underwriting and policy issuance. I further authorize third parties to release such information upon request.

I understand that renewal of coverage is subject to underwriting approval and acceptance of any revised premium or terms. Renewal will become effective only upon issuance of a renewal policy or endorsement and, where required, receipt of any applicable premium payment.

Certification: By checking this box I certify that the statements made in this application are true and complete, and I accept the declarations and authorizations above.

9. ADDITIONAL ATTACHMENTS

Attach any supporting documentation required for underwriting review (e.g., repair invoices, proof of residence, motor vehicle record consent forms, medical documentation where applicable). Describe attachments:

Sign Now