Insurance Servicing ROA

INSURANCE SERVICING ROA

ROA Number:    Date Prepared:    Prepared By:

Insured / Applicant Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Period From:    To:

Underwriter:    Agent/Broker:

Servicing Action Requested

Select action(s) to be performed (check all that apply):

Requested Effective Date:    Requested By (name):

Supporting Documentation Checklist

Beneficiary Designation (if applicable)

Relationship:    Percentage:

Relationship:    Percentage:

Note: The insured certifies allocation percentages and understands that total designated percentages should equal 100. The insurer will rely on the most recent valid beneficiary designation on file.

Coverage Impact, Exclusions, and Estimated Adjustment

Will the requested action increase coverage exposure or change risk profile?    Yes No

Exclusions: The insurer's acceptance of this ROA is subject to policy terms, endorsements, and applicable exclusions. No amendment to coverage is effective unless issued by the insurer in writing. Changes retroactive to dates prior to insurer approval may be denied or modified.

Underwriting / Servicing Notes (Internal)

Approval Required: Yes No

Declaration, Authorization, and Certification

By signing below, the insured certifies that the information contained in this Insurance Servicing ROA is true, complete, and accurate to the best of the insured's knowledge. The insured authorizes the insurer, its agents, designees and service providers to undertake the requested servicing actions and to obtain, use, and disclose personal and policy information as reasonably necessary to effect the transaction. The insured acknowledges that any change requested may result in premium adjustment, endorsement issuance, or other administrative action, and that those changes are subject to insurer underwriting review and final approval.

The insured further represents that no material facts or circumstances have been withheld and agrees to indemnify and hold the insurer harmless from any liability arising from misrepresentations or failures to disclose material information. This ROA constitutes the insured's written authorization to act as specified herein and shall be binding on the insured upon signature. Any amendment or revocation of this ROA must be submitted in writing and accepted by the insurer in writing.

Governing Law: This ROA shall be governed by and construed in accordance with the laws applicable to the policy contract and the insurer's place of business. The insured acknowledges receipt of a copy of this completed ROA.

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