Insurance Risk Application

INSURANCE RISK APPLICATION

Applicant / Insured Information

Individual    Corporation    Partnership    Limited Liability Company (LLC)    Other:

Policy Details

Policy type requested: General Liability    Property    Professional / E&O    Commercial Auto    Umbrella/Excess

Policy period requested — From:    To:

Risk Details

Alarms/Monitoring    Automatic sprinklers    Security personnel    Documented safety program    Other:

Coverage Options (select and specify limits)

General Liability — Limit:

Property — Covered values:

Professional / E&O — Limit:

Commercial Auto — Combined single limit:

Exclusions and Conditions

The coverage applied for will be subject to standard policy exclusions, including but not limited to: intentional acts, criminal acts by the insured, pollution and contamination unless specifically endorsed, war and nuclear hazard, and any other exclusions required by the insurer after underwriting review. The insurer reserves the right to impose additional exclusions or higher deductibles based on underwriting findings. Applicant acknowledges that any material misrepresentation, omission or concealment of fact in this application may void coverage and relieve the insurer of liability.

Prior Claims and Loss History

Has any similar insurance been declined, cancelled, or non-renewed in the past 5 years?    Yes    No

Have there been any claims or incidents in the past 5 years?    Yes    No

Documentation Checklist

Please attach or make available the following documents. Check those you have provided:

Loss runs (past 5 years)    Financial statements    Photographs of premises    Safety manual / training records    Other:

Beneficiary Information (if applicable)

Beneficiary 1

Beneficiary 2 (optional)

Declarations and Certification

By signing this application, the applicant certifies that all statements and information provided herein are true, complete and correct to the best of the applicant's knowledge. The applicant understands that this information will be relied upon by the insurer in determining eligibility, terms, conditions and premium. The applicant acknowledges that any material misrepresentation, omission, or concealment of fact may constitute grounds for denial of coverage, rescission of the policy, or forfeiture of premiums.

The applicant authorizes the insurer and its representatives to obtain and verify information from any source, including but not limited to loss history, credit, reservation databases, regulatory or licensing bodies, and other insurers or their agents. The applicant agrees to provide documentation reasonably requested by the insurer for underwriting purposes and to permit inspection of the premises, operations and records where necessary.

The applicant further acknowledges that coverage, if issued, will be governed by the terms, conditions and endorsements of the issued policy. Payment of premium, issuance of policy documents and application of required endorsements are conditions precedent to coverage. The applicant agrees to notify the insurer promptly of any material change in risk or exposure occurring between application and policy inception.

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