Insurance Supplemental Renewal

INSURANCE SUPPLEMENTAL RENEWAL

This Supplemental Renewal amends and supplements the terms of the existing policy identified below and is subject to the terms, conditions, exclusions, and endorsements of the underlying policy unless specifically modified herein. Policy Number:    Effective Date:    Expiration Date:

Insured / Applicant Information

Policy Details

Policy Type (check all that apply):

Commercial Property    General Liability    Auto    Professional Liability

Homeowners    Umbrella    Other:

Automatic renewal of policy subject to premium and underwriting review.   Renewal with changes as specified in this supplemental renewal.

Supplemental Changes / Endorsements

Set forth below are the specific endorsements, changes to coverage, or limitations to be attached to the policy upon renewal. If no endorsement is applicable, indicate "None" in the title field.

Coverage Extensions / Optional Coverages

Select coverage extensions to be added or continued under renewed policy (if available under policy form and subject to additional premium).

Ordinance or Law    Business Interruption    Equipment Breakdown

Cyber Liability    Employee Dishonesty    Medical Payments

Exclusions and Acknowledgements

The following standard exclusions apply unless specifically endorsed. Applicant acknowledges reading and understanding these exclusions by checking the boxes below where indicated.

Earthquake exclusion acknowledged    Flood exclusion acknowledged

War and terrorism exclusion acknowledged    Wear and tear / gradual deterioration exclusion acknowledged

Beneficiary Designation (if applicable)

Designate primary beneficiary(ies) for proceeds payable under the policy type requiring such designation. If none, write "None".

Declarations and Certifications

By signing below, the undersigned declares and certifies that all information provided in this Supplemental Renewal is true, complete, and accurate to the best of the undersigned's knowledge. The undersigned acknowledges that any material misrepresentation, omission, or concealment of fact may result in denial of coverage, rescission of the policy, or other remedies available to the insurer under applicable law and the policy.

The undersigned understands and agrees that this Supplemental Renewal, when accepted by the insurer, will form a part of the policy and will modify coverage only as specifically stated. Renewal coverage becomes effective only upon payment of any required premium or installment thereof and issuance of the corresponding endorsement by the insurer. Premium adjustments reflected in this supplemental shall be subject to audit and correction following review of actual exposures.

The undersigned agrees to notify the insurer promptly of any material change in risk prior to the effective date of renewal, including but not limited to changes in occupancy, operations, location, valuation, or prior losses. Failure to provide timely notice of such material changes may void coverage as to those changes.

Applicant authorizes insurer to adjust premium based on audit, underwriting review, or post-renewal correction of exposures.

No material change in risk has occurred since the policy inception or last renewal that has not been disclosed to the insurer.    Material change described below. If yes, describe:

Agent / Broker Acknowledgement (if applicable)

Agent or broker must verify any underwriting changes and confirm the insured's instructions for renewal. Agent Name:

Agency:

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