Insurance Renewal Form

Insurance Renewal Form

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Existing Policy Details

Policy Number:    Policy Type:

Current Coverage Limit: $    Deductible: $

Current Annual Premium: $    Policy Period: From to

Proposed Renewal Coverage

Select coverages to renew or change. Check to retain or amend and indicate proposed limit or deductible where applicable.

Proposed Coverage Limit: $    Proposed Deductible: $

Liability Limit: $    Comprehensive Deductible: $

Umbrella Limit: $

Changes Since Prior Policy

Have there been any material changes to risk exposure since the prior policy period (for example: change of occupancy, major renovations, new drivers, business use, removed structures)?   Yes   No

Claims History (Most Recent Policy Period)

Have you had any claims, losses or incidents that might give rise to a claim during the last policy period?   Yes   No

Documentation provided with this renewal: Police report Repair estimate Photographs

Beneficiary / Additional Insured

Relationship:    Percentage: %

Relationship:    Percentage: %

Payment & Billing

Renewal Premium Due: $    Payment Frequency: Annual Semi-annual Monthly

Exclusions & Notices

The policy does not cover loss or liability caused directly or indirectly by war, nuclear hazard, intentional acts by the insured, wear and tear, or fraudulent acts. Additional exclusions may apply per the policy form. By renewing you acknowledge you have reviewed the standard exclusions and any endorsements that apply to this policy.

I acknowledge that I have reviewed the exclusion summary and understand that coverage is subject to terms, conditions and exclusions of the renewed policy.

Declarations and Certification

I certify that the statements and information contained in this Insurance Renewal Form are complete and true to the best of my knowledge. I understand that any material misrepresentation, misstatement, or omission may be grounds for denial of coverage or rescission of the policy. I agree to notify the insurer promptly of any material change in risk during the renewal process or prior to policy effective date.

I authorize the insurer to obtain and verify any records necessary to underwrite the renewal, including prior claims information, driving records, inspection reports, and other relevant underwriting data. I consent to the insurer adjusting the renewal premium based on the information provided and any underwriting requirements.

Fraud Warning: Any person who knowingly presents false information or conceals a material fact in order to obtain insurance coverage or benefits may be committing insurance fraud and may be subject to civil and criminal penalties.

By checking this box I certify that the information provided in this form is true and that I understand the insurer may rely upon these statements in issuing the renewal.

Sign Now