Insurance Service Life Declaration

INSURANCE SERVICE LIFE DECLARATION

Purpose: This Insurance Service Life Declaration is submitted by the Applicant to record the original and estimated remaining useful service life of the insured property for underwriting and claims evaluation. The Applicant certifies that the statements contained herein are true and complete to the best of the Applicant's knowledge and that deliberate misrepresentation may constitute grounds for denial of coverage or policy rescission.

Applicant / Insured Information

Individual   Corporation   Partnership   Trust

Policy Details

Property Insurance   Motor Vehicle   Equipment Breakdown   Specialty/Other

Insured Item / Equipment Details

Service Life Declaration

Applicant Name:

I affirm that the insured item described above was placed into service on . At the time of original placement into service the expected useful service life was years. As of the date of this Declaration, the estimated remaining useful service life is years.

The estimate of remaining service life is based on the following factors (check all that apply and attach supporting records):

Manufacturer's recommended service life
Documented maintenance and repair history
Recent independent inspection/report
Actual hours of use or mileage
Other (specify):

Maintenance, Modifications and Loss History

Has the item undergone material modification since original purchase? Yes No

Has the item sustained significant loss, damage, or major repairs? Yes No

Coverage Requested and Limits

Requested additional or specific coverage endorsements (check all applicable):

Spare Parts Coverage
Agreed Value Endorsement
Depreciation Waiver
Other (specify):

Exclusions and Limitations

The Applicant acknowledges that declared service life estimates do not modify or negate any policy terms, conditions, or exclusions. Typical exclusions that remain applicable include but are not limited to wear and tear, gradual deterioration, inherent vice, corrosion, and failure to maintain. Acceptance of this Declaration does not expand coverage for excluded perils.

Applicant acknowledges receipt of and agreement to the foregoing exclusions: I hereby acknowledge

Beneficiary Designation

Beneficiary Name:

Relationship to Applicant:

Percentage Allocation: %

Supporting Documentation Checklist

Please attach copies of applicable documents (check all that are attached):

Purchase invoice / sales receipt
Maintenance and repair records
Independent inspection report
Photographs of the item
Other (specify):

Declaration and Certification

By signing below, I certify under penalty of law that the information provided in this Insurance Service Life Declaration is true, correct and complete. I understand that any material misrepresentation or omission may void coverage for the insured item and may subject me to civil remedies. I authorize the insurer to rely on this Declaration for underwriting and claim determinations.

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