Insurance Risk Document

INSURANCE RISK DOCUMENT

Applicant / Insured Information

Client Name:

Mailing Address:

Date of Birth:    Tax ID / SSN (last 4):

Policy Details

Policy Type:    Policy Effective Date:    Policy Expiration Date:

Coverage Limit: $    Deductible: $    Annual Premium: $

Coverage Selection

Select coverages requested (check all that apply):

General Liability

Property (Building / Contents)

Business Interruption

Automobile / Hired & Non-Owned Auto

Cyber Liability

Flood    Earthquake

Risk Description and Exposures

Loss History

Provide details for all claims or losses in the past five years. Attach additional pages if necessary.

Exclusions and Acknowledgements

The following contain typical exclusions which may apply to the coverages requested. Check to acknowledge you have reviewed and understand these exclusions.

Exclusion: War, civil war, insurrection, and hostile acts.

Exclusion: Nuclear hazard and radioactive contamination.

Exclusion: Losses arising from communicable disease where specifically excluded.

Exclusion: Intentional acts or deliberate non-compliance with law.

I acknowledge that additional policy-specific exclusions may apply and that final coverage determinations are governed by the policy form and endorsements issued by the insurer.

Beneficiary / Payee (if applicable)

Beneficiary Name:

Relationship to Insured:    Allocation Percentage:

Declarations, Representations and Authorizations

I represent and warrant that the information provided in this Insurance Risk Document is true, complete and correct to the best of my knowledge. I understand that material misrepresentation, concealment or omission of facts may result in denial of coverage, rescission of the policy, or adjustment of premiums and benefits in accordance with policy terms and applicable law.

I authorize the insurer and its representatives to obtain and verify any information necessary to evaluate risk, to conduct underwriting, and to perform claims investigation; this includes but is not limited to loss history, inspection reports, and publicly available records. I consent to the release of claim and underwriting information to reinsurers and to other insurers for purposes of evaluation and fraud prevention.

I agree to promptly notify the insurer of any material changes in risk, business operations, or occupancy that occur prior to or during the policy period. Failure to provide timely notice may affect coverage.

By signing below I certify under penalty of perjury that the foregoing statements are true and complete.

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