Insurance Renewal Offers

INSURANCE RENEWAL OFFER

Applicant / Insured Information

Date of Birth:   Phone:   Email:

Policy Details — Existing Policy

Policy Number:   Policy Type:

Current Coverage Limit: $   Current Deductible: $

Policy Period — Effective:   Through:

Renewal Offer Summary

Renewal Offered: Yes    No

Proposed Coverage Limit: $   Proposed Deductible: $

Proposed Annual Premium: $   Payment Frequency: Annual Semi-Annual Monthly

Renewal Premium Due Date:

Coverage Options & Selections

Select coverages to be included in the renewal policy. Checking a box authorizes inclusion of that coverage subject to the terms below.

Property (Dwelling / Building) — Limit $

Liability — Limit $

Auto (if applicable) — Limit $

Theft / Vandalism      Business Interruption

Material Changes & Exclusions

The renewal offer is subject to the following specific exclusions and endorsements. These will apply to the renewed policy unless otherwise agreed in writing.

Flood damage exclusion (no flood coverage provided)

Earthquake exclusion (no earthquake coverage provided)

Wear and tear / gradual deterioration excluded

If any material facts have changed since the inception of the current policy (such as occupancy, business operations, prior losses, modifications to the insured property, or drivers for auto coverage), disclose those changes in the field below. Failure to disclose material changes may result in rescission of coverage or denial of claims.

Beneficiary Designation (If Applicable)

Designate a beneficiary where applicable to the policy type. Percentages must total 100% where multiple beneficiaries are listed.

Payment Authorization

By checking the authorization box and signing below, Applicant authorizes the insurer to charge or invoice the renewal premium in accordance with the selected payment frequency and method. This authorization does not constitute acceptance until executed by Applicant and acknowledged by the insurer.

I authorize premium collection as indicated and request renewal processing.

Credit Card (last 4 digits):    Bank Transfer (last 4 of account):    Check

Attachments / Documentation

Please indicate documents attached to support the renewal evaluation. Retain copies for your records. Submission of incomplete or false documentation may affect coverage.

Property photos

Loss history / claims documentation

Inspection report

Declaration and Certification

I certify under penalty of false statements that the information provided in this Insurance Renewal Offer response is complete, true, and accurate to the best of my knowledge. I understand that acceptance of this renewal offer by the insurer is conditioned upon underwriting review and payment of the premium by the due date. I acknowledge that material misrepresentation, omission, or concealment of facts may render the renewed policy void or may result in denial of claims.

I further acknowledge that the insurer may add endorsements, conditions, or exclusions to address changes in exposure or underwriting requirements. Any change to coverage beyond the terms stated in this offer must be confirmed in writing by an authorized representative of the insurer.

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