Insurance Supplementary Application

INSURANCE SUPPLEMENTARY APPLICATION

Applicant / Insured Information

Policy Details

Policy Number:    Policy Type:

Policy Period: From to

Supplemental Underwriting Questions

The following questions supplement the original application. Check each box that applies and provide details where requested. Omissions or misrepresentations may result in denial of coverage or rescission of the policy.

1. Has the applicant had any losses, claims, or incidents not previously reported to the insurer since the original application? Check to report: Yes

2. Has any insurer declined, cancelled, or refused to renew any policy for the applicant within the past five years? Check to report: Yes

3. Has there been any material change in occupancy, use, or risk exposure since the original application (for property: vacancy, renovations, rental use; for auto/business: additional drivers, new operations)? Check if applicable: Yes

Coverage Options and Endorsements Requested

Select coverages or endorsements to be added, modified, or reviewed. Attach supporting documentation where required.

Property Coverage (limit: ) Amount:

Liability Coverage (limit: ) Amount:

Loss of Use / Business Interruption Coverage

Exclusions, Limitations, and Notices

The insurer reserves the right to add, modify or clarify policy exclusions and limitations based upon the information provided. Failure to disclose facts material to underwriting or any attempt to obtain coverage by misrepresentation or concealment of material facts may result in denial of coverage, rescission of the policy, or the imposition of retroactive premium. The applicant must notify the insurer in writing of any change in risk or condition that would render statements in this application inaccurate.

Beneficiary Designation (if applicable)

Beneficiary Name:

Documentation Checklist

Please attach or provide the following supporting materials where applicable. Check each item submitted.

Prior policy declarations / loss runs (past 5 years)

Photographs of property, vehicle, or operations

Repair estimates or contractor bids

Police/fire reports or incident reports

Declaration and Certification

I certify that the information contained in this Supplementary Application is true, complete and correct to the best of my knowledge. I acknowledge that this Supplement is part of and forms the basis of the policy to which it is attached. I further authorize the insurer and its authorized representatives to obtain and verify, by any lawful means, any information necessary for underwriting, rating, or claims handling, including but not limited to prior loss history, credit, claims databases and other relevant records. I understand that any material misrepresentation, omission or concealment of fact may result in denial of coverage, rescission of the policy, or voiding of coverage from inception to the extent permitted by law.

Fraud Warning: Where applicable by law, any person who knowingly presents false or fraudulent information in this application for insurance may be guilty of a criminal offense and may be subject to civil penalties and forfeiture of benefits.

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