Insurance Renewal Quotes

INSURANCE RENEWAL QUOTES

Quote Number:     Date Issued:     Prepared By:

Applicant / Insured Information

Insured Name:

Contact Name:     Phone:     Email:

Date of Birth (if individual insured):

Existing Policy Details

Current Policy Number:     Current Insurer:

Policy Type:

Coverage Limit (Aggregate):     Deductible:     Annual Premium:

Current Policy Period From:     To:

Renewal Quote Options

Select one renewal option. Each option is subject to underwriting review and issuance of policy documentation.

Coverage Selections

Select coverages proposed for renewal. Limits and sublimits must be specified where applicable.

General Liability — Limit:

Property (Buildings/Contents) — Limit:

Business Interruption — Limit:

Cyber Liability — Limit:

Commercial Auto — Limit:

Workers' Compensation — Limit:

Exclusions and Endorsements

Standard exclusions (examples): intentional acts, pollution not endorsed, war and nuclear perils, fraud and criminal acts. Specific endorsements or deviations proposed are set forth below.

I acknowledge I have reviewed the exclusions and endorsements proposed above and understand that final policy terms may vary upon underwriting review.

Beneficiary / Loss Payee (if applicable)

Beneficiary 1 Name:

Relationship:     Percentage:

Beneficiary 2 Name:

Relationship:     Percentage:

Premium, Payment and Validity

Premium Payment Terms:

Deposit / Down Payment Required:

Quote Valid For: days from date issued.

Declarations and Certifications

By signing below the applicant certifies that all information provided in this renewal quote request is true, complete and accurate to the best of the applicant's knowledge. The applicant understands that any material misrepresentation, omission or concealment of fact may result in modification or rescission of coverage, as permitted by law and policy terms.

This document constitutes a quotation only. No coverage is bound until the insurer issues policy documents and the required premium or deposit is received. Insurer reserves the right to amend terms for any material change in risk or discovery of previously undisclosed facts.

Fraud Warning: Any knowingly false statement or omission may constitute insurance fraud in accordance with applicable law and may be subject to civil or criminal penalties.

Authorization: Applicant authorizes the insurer and its representatives to obtain and exchange underwriting, claims and loss information necessary to evaluate this renewal. Applicant also authorizes premium payment processing as described in the payment terms above.

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