Insurance Renewal Signature Forms

INSURANCE RENEWAL SIGNATURE FORM

Applicant / Insured Information

Date of Birth:    Policy Number:

Telephone:    Email:

Policy Renewal Details

Renewal Effective Date:    Renewal Expiration Date:

General Liability    Property (Commercial/Residential)    Commercial Auto    Professional Liability    Life / Personal Accident

Coverage Limit(s):

Deductible:    Annual Premium:

Coverage Elections and Endorsements

I elect to renew coverage as indicated below. I understand that requested endorsements become effective only upon acceptance and processing by the insurer.

Add Additional Insured endorsement    Waiver of Subrogation    Hired and Non-Owned Auto Liability

Material Change Disclosure

Since the inception of the current policy, have there been any material changes in risk exposure, operations, ownership, or occupancy?    Yes    No

Exclusions and Acknowledgements

I acknowledge that standard policy exclusions, including but not limited to war, nuclear hazard, intentional acts, and prior known losses, remain applicable unless expressly amended in a written endorsement issued by the insurer.

I acknowledge that failure to disclose material facts or submitting materially false information may result in denial of coverage, rescission of the policy, or adjustment of claim payments.

Beneficiary Designation (if applicable)

Relationship:    Share (%):

Premium Payment and Authorization

Payment Method:    Payment Frequency:

I authorize the insurer or its agent to charge the payment method provided for the premium due upon renewal and any applicable fees authorized under the policy terms.

Documentation Checklist

The following documentation is required to process renewal endorsements or changes. Please indicate included items:

Prior policy declarations page    Loss run / claims history    Photographs / inspection reports    Contracts / agreements affecting exposure

Declaration and Authorization

I declare that the information provided on this form and in any attachments is true, complete and correct to the best of my knowledge. I understand that this authorization and any statement made herein will become part of the policy application and may be relied upon by the insurer in deciding whether to renew or modify coverage. I acknowledge that any material misrepresentation or omission may be grounds for denial of coverage or rescission of the policy.

I authorize the insurer and its authorized representatives to obtain and verify information necessary for renewal, including loss history, claims information, and other underwriting information. I further authorize payment of premium as specified and consent to issuance of any endorsements reflecting changes requested herein upon insurer acceptance.

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