Insurance Renters Signature Pages

INSURANCE RENTERS SIGNATURE PAGES

Client Name:    Policy Number:

Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Type: Personal Property Personal Liability Medical Payments

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period Effective Date:    Expiration Date:

Optional Coverages & Endorsements

Replacement Cost for Contents

Water Backup Endorsement    Limit: $

Exclusions and Important Notices

The insured acknowledges that coverage provided by this policy is subject to all terms, conditions, limitations and exclusions contained in the policy contract and any attached endorsements. By signing below the insured confirms receipt of the applicable policy declarations and acknowledges the following material exclusions: damage from intentional acts, wear and tear, pest infestation, losses from criminal acts committed by an insured, and losses excluded by ordinance or law.

I acknowledge that I have read and understand the exclusions listed above:

Beneficiary / Additional Payee for Personal Property Settlement

Designation applies only for settlement of insured personal property where payment to a third party is requested.

Relationship:    Percentage of Settlement:

Relationship:    Percentage of Settlement:

Claims Information (if submitting a claim)

Date of Loss:

Estimated Damage Amount: $

Police Report    Photographs    Receipts / Proof of Purchase    Repair Estimates

Declaration and Certification

I certify that the information provided on these signature pages and any attachments is true, complete and accurate to the best of my knowledge. I understand that any intentional misrepresentation of material facts may result in denial of coverage, rescission of the policy, or other lawful remedies. I authorize the insurer to obtain information necessary to underwrite and administer the policy, including but not limited to underwriting, claims handling and fraud prevention. I acknowledge that coverage is afforded only in accordance with the written policy, its endorsements and any applicable state law.

I further acknowledge receipt of the policy declarations and any endorsements indicated above and request the policy be issued or amended in accordance with the selections and representations made on these signature pages.

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