Insurance Renewal Applications

INSURANCE RENEWAL APPLICATION

Applicant / Insured Information

Applicant Name:

Insured Entity Type: Individual Company

Date of Birth:

Policy Details

Policy Type: Auto Homeowners Life Commercial Professional Liability

Policy Period Start: End:

Renewal Term (months):

Coverages (select all that apply)

Liability Property Damage Bodily Injury Collision Comprehensive Uninsured/Underinsured Motorist Medical Payments Personal Property Business Interruption

Claims and Loss History

Have you had any claims, losses, or incidents during the prior policy period? Yes No

Date of Loss 1: Estimated Amount:

Date of Loss 2: Estimated Amount:

Date of Loss 3: Estimated Amount:

Changes to Risk / Material Alterations

Since the inception of the current policy, have there been any material changes in occupancy, operations, equipment, drivers, or uses that would affect underwriting? Yes No

Beneficiary Designation (if applicable)

Primary Beneficiary 1 Name

Contingent Beneficiary 2 Name

Exclusions and Endorsements

Standard exclusions that may apply include but are not limited to: intentional acts, wear and tear, nuclear hazard, war, pollution unless specifically endorsed, and fraudulent acts. Additional endorsements may be required to cover specific perils.

Declarations and Certification

I hereby declare that all statements and answers in this Renewal Application are true and complete to the best of my knowledge and belief. I understand that the Company will rely upon this information in determining eligibility for renewal and the terms of the renewed policy. Material misrepresentation or omission of fact may result in denial of renewal, cancellation, voidance of coverage, or adjustment of premium.

I authorize the insurer to make any inquiries necessary to verify the information provided, including but not limited to inspection of property, review of claims history, driving records, loss run reports, and other underwriting data. I agree to notify the insurer promptly of any material change in risk that occurs prior to the effective date of renewal.

Fraud Warning: Any person who knowingly and with intent to defraud the insurer submits an application or statement containing false information or conceals information may be subject to denial of coverage, civil penalties, and criminal prosecution.

Attestation: I certify that the information provided in this application is true and accurate. I authorize release of records and information necessary for underwriting and claims handling.

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