Insurance Supplement Application

INSURANCE SUPPLEMENT APPLICATION

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Existing Policy Details

Policy Type:

Policy Period From:    To:

Supplement Request

Please indicate the nature of the requested supplement (check all that apply):

Increase policy limits
Add or change insured location(s)
Add vehicle(s) or equipment
Change beneficiary or allocations
Add endorsement(s) or additional coverage
Other (describe below)

Requested Coverage Adjustments

Coverage Selection (Check all that apply)

Liability (Bodily Injury / Property Damage)
Property (Building / Dwelling)
Personal/Contents Property
Business Interruption / Loss of Income
Medical Payments
Uninsured / Underinsured Motorist
Collision (Auto)
Comprehensive (Auto/Equipment)

Exclusions and Acknowledgements

The following are common exclusions and conditions. The insurer retains underwriting discretion to apply additional exclusions or adjust terms. The applicant acknowledges review of the following statements and understands that endorsement language or policy terms will control coverage.

• Losses arising from intentional acts, fraud, war, nuclear hazard, and pollution unless specifically endorsed.
• Wear and tear, deterioration, and mechanical breakdown are excluded unless specifically endorsed.
• Coverage for newly added property or scheduled items may be subject to valuation limits and proof of ownership.

I acknowledge the exclusions above and understand additional exclusions may apply upon underwriting review.

Beneficiary / Payee Designation

Designate beneficiaries for claim proceeds or policy payable amounts resulting from this supplement. Percentages should total 100%.

Supporting Documentation Checklist

Attach copies of the following documents where applicable. Failure to supply required documentation may delay underwriting.

Photographs of property / equipment
Purchase invoices or receipts
Independent appraisal or valuation
Prior loss history / claims reports
Other supporting documentation attached

Declaration and Certification

I certify that the statements and representations contained in this Insurance Supplement Application are true, complete and correct to the best of my knowledge. I understand that any material misrepresentation, omission, or concealment of a fact may constitute grounds for denial of the supplement, rescission of coverage, or other remedies available to the insurer under applicable law.

I authorize the insurer, its representatives or authorized agents to obtain and verify any information necessary to evaluate this supplement request, including but not limited to claims history, inspection reports, photographs, and other records. I understand that underwriting review may result in modifications to the requested coverage, changes to premium, additional endorsements, or the requirement for inspections prior to effective coverage.

I acknowledge that submission of this form does not in itself bind coverage. Coverage becomes effective only upon acceptance and issuance of endorsement or other binding documentation by the insurer.

Fraud Warning: Where permitted by law, any person who knowingly submits false or fraudulent information may be subject to civil or criminal penalties and denial of coverage.

By signing below I attest under penalty of perjury that the information provided in this supplement application is true, accurate, and complete.

Sign Now