Insurance Renewal Policy

INSURANCE RENEWAL POLICY

Policy Identification

Policy Number:    Renewal Effective Date:

Issuing Company:

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details & Premium

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period From:    To:

Annual payment
Installment plan (subject to terms)
Direct debit authorization on file

Coverage Options (Select applicable)

Property Damage
General Liability
Business Interruption
Comprehensive
Collision
Theft
Medical Payments / Personal Injury Protection
Other (specify below)

Endorsements & Changes Requested

Exclusions & Acknowledgements

Standard policy exclusions apply and include, without limitation: loss caused by intentional acts, war or similar perils, wear and tear, gradual deterioration, pollution (unless specifically endorsed), and loss arising from fraudulent or illegal activity. The applicant acknowledges that additional exclusions may apply by endorsement.

I acknowledge I have read and understand the exclusions and limitations of coverage as set forth in the renewed policy and any applied endorsements.

Beneficiary / Loss Payee Information

Primary Beneficiary Name

Relationship

Percentage of Benefit

Secondary Beneficiary Name (optional)

Relationship

Percentage of Benefit

Declarations, Representations, and Conditions

The Applicant represents and warrants that all statements and answers set forth in this renewal request are true and complete to the best of Applicant's knowledge. The Applicant understands that any material misrepresentation, omission, or concealment of fact may render the policy voidable or entitle the Company to rescind coverage in accordance with the policy terms and applicable law.

Coverage under the renewed policy is conditioned upon payment of premium in full or in accordance with an approved payment plan. Failure to pay the premium or any required installment when due shall permit the Company to cancel coverage in accordance with the policy terms.

The Applicant agrees to promptly notify the Company in writing of any change in risk, material change in operations, or any other matter that would reasonably affect the Company’s underwriting of the risk. The Company may modify, restrict, or cancel coverage where the risk has materially changed.

Subrogation: The Company shall have all rights of subrogation against any person or entity to the extent of any payment made under the policy. The Applicant agrees to cooperate fully in any subrogation proceedings.

Governing Law: The renewed policy and this renewal agreement shall be governed by the laws specified in the policy contract or, absent such provision, by the laws of the jurisdiction where the policy was issued.

Fraud Warning & Authorization

It is a crime to knowingly provide false, incomplete or misleading information for the purpose of defrauding an insurer. Penalties may include fines and imprisonment. The Applicant authorizes the Company to obtain such information as reasonably necessary to underwrite, bind, reinstate or service this policy, including obtaining consumer reports or loss history information where permitted by law.

I authorize the Company to obtain underwriting, claims and other information necessary to evaluate this renewal and any endorsements or claims.

Attachments & Documentation Checklist

Please attach required documentation as indicated: proof of prior loss control measures, current inventory lists, photos of insured property (if applicable), prior policy declarations, and any requested endorsements.

Prior policy declarations attached
Loss photos / inventory attached
Loss control documentation attached

Applicant Certification

By signing below, the Applicant certifies that the statements contained herein are true and complete, that the Applicant has the authority to request renewal on the insured risk, and that the Applicant accepts the terms, conditions, limitations, and exclusions described in this renewal request and in the renewed policy documents to be issued by the Company.

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