Insurance Renewal Information Form

INSURANCE RENEWAL INFORMATION FORM

Policy Number:    Renewal Effective Date:

1. Insured / Applicant Information

2. Policy Details & Renewal Terms

Policy Type: Auto    Homeowner    Renters    Umbrella    Life    Commercial   Other:

Policy Period: From to

3. Selected Coverages

Select coverages to be in force during the renewal period (check all that apply).

Liability    Collision    Comprehensive    Personal Property    Medical Payments

Additional Living Expenses    Replacement Cost    Business Interruption    Other:

4. Changes Since Prior Policy

Indicate any material changes since the prior policy period:

No material changes    Change of address    New drivers

Vehicles added/removed    Renovations/structural changes    Business use of premises

5. Claims History (Last 5 Years)

No claims in the last five years    One or more claims in the last five years

Provide details for each claim. If more space is required, attach an addendum signed by the insured.

6. Beneficiary Designation

Complete beneficiary information if policy or selected coverages require a beneficiary designation.

Alternate Beneficiary (if any):

7. Exclusions, Notices and Declarations

The insurer will renew the policy subject to all terms, conditions, and exclusions contained in the policy contract. Material misrepresentation, nondisclosure, or failure to report changes in risk or exposure may result in denial of coverage, rescission, or termination of the policy as permitted by law and the policy terms. The insured must promptly report any changes that materially affect risk.

Coverage exclusions that commonly apply include but are not limited to: intentional acts, fraudulent claims, wear and tear, war and nuclear loss, and loss or damage arising from illegal acts by the insured. This form does not alter the policy contract; it is an administrative record of renewal information and representations made by the insured.

I authorize the insurer to automatically renew the policy at the end of the current term subject to underwriting approval and premium adjustment.

8. Authorization & Certification

By signing below, I certify under penalty of perjury that the information provided on this Insurance Renewal Information Form is complete and accurate to the best of my knowledge. I understand that this information will be relied upon by the insurer in evaluating coverage and determining premiums. I acknowledge that any material misstatement or omission may constitute grounds for rescission, denial of claims, or policy cancellation in accordance with the policy terms and applicable law.

I authorize the insurer and its representatives to obtain and review records and information necessary to underwrite and service the policy, including but not limited to motor vehicle records, claims history, loss runs, property inspections, and other relevant underwriting information. I further authorize the release of information to reinsurers and third-party administrators as required for policy administration.

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