Insurance Setup Form

Insurance Setup Form

Applicant / Insured Information

Date of Birth:    Social Security / Tax ID:

Policy Details

Policy Type:

Coverage Amount: $    Deductible: $    Annual Premium: $

Policy Period From: to

Electronic Auto-Debit    Invoice/Bill    Credit/Debit Card on File

Coverage Selections

Select coverages to be included in the policy (check all that apply). Selected coverages are subject to underwriting approval and the terms, conditions and exclusions of the issued policy.

General Liability    Property Damage    Professional Liability (E&O)

Business Interruption    Automobile Liability    Workers' Compensation

Exclusions and Limitations

The policy will contain standard and specific exclusions. The following are examples of exclusions commonly applied and may be included in the final policy if applicable: intentional acts, punitive damages where not insurable by law, war and nuclear hazards, fraud, employee dishonesty not specifically endorsed, and losses arising from illegal activity. Applicant must disclose all material facts; nondisclosure or material misrepresentation may render the policy voidable from inception.

Beneficiary Designation

If applicable, designate primary beneficiaries for policy proceeds. Percentages must total 100% for all primary beneficiaries.

Relationship:    Percentage: %

Relationship:    Percentage: %

Claims and Loss Reporting

Claims Phone:    Claims Email:

Declarations and Certification

The Applicant declares that the information provided in this form is true, complete, and correct to the best of Applicant's knowledge. Applicant acknowledges that any material misrepresentation, omission, or concealment of fact may result in denial of coverage, cancellation of the policy, or rescission of coverage from the inception date. Applicant authorizes the insurer and its agents to obtain and exchange underwriting and claims information, including but not limited to prior policy history, loss runs, and claim investigation results, as permitted by applicable law.

Applicant understands that issuance of a binder or policy is subject to underwriting review and approval. Coverage, limits, deductibles, endorsements, and exclusions will be set forth in the policy documents and control the rights and obligations of the parties. Premium payment obligations are governed by the terms of the bill and policy; failure to pay premiums when due may result in lapse or cancellation.

I acknowledge receipt of applicable fraud warnings where required by law and understand that knowingly providing false information may constitute insurance fraud.

Applicant consents to electronic delivery of policy documents where permitted and agrees that electronic signatures and electronic records satisfy any legal requirement for original signatures.

By signing below, the Applicant certifies the accuracy of the information provided, acknowledges the declarations above, and requests the insurer to issue coverage in accordance with the selections and disclosures in this form, subject to underwriting approval and issuance of a policy document.

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