Insurance Tenant Policy

INSURANCE TENANT POLICY

Policy Identification

Insurer Name:    Policy Number:

Effective Date:    Expiration Date:

Insured (Applicant) Information

Date of Birth:    Phone:    Email:

Policy Coverages and Limits

Coverage Type:    Annual Premium: $    Deductible: $

Coverage Selections (check to include):

Personal Property Coverage — Limit $

Personal Liability Coverage — Limit $

Medical Payments to Others — Limit $

Additional Living Expenses (ALE) — Limit $

Optional Endorsements

Water Backup/Sump Overflow Endorsement — Additional Premium $

Loss of Use / Rental Income Protection — Additional Premium $

Exclusions and Limitations

The following are examples of material exclusions under this policy. Coverage is subject to the full terms, conditions and exclusions contained in the policy contract, including endorsements:

• Loss caused by flood, earthquake, war, nuclear hazard, or government seizure, unless a specific endorsement is attached.
• Intentional acts or dishonest acts by the insured; losses resulting from criminal activity by the insured.
• Wear and tear, gradual deterioration, mold or infestation except where sudden and accidental and otherwise covered.
• Business property and liabilities arising from business pursuits unless specifically endorsed.

Beneficiary Designation

Designated payee for covered losses or proceeds:

Claims Reporting and Proof

The insured must notify the insurer promptly of any loss or occurrence likely to give rise to a claim. The insured shall: (a) provide written notice describing the loss and date of loss; (b) furnish reasonable proof of loss, including inventories, receipts, photographs and estimates; (c) cooperate with any reasonable investigation and evidence gathering requested by the insurer.

Date of Loss (for reporting existing incidents):

Payments, Cancellation and Nonpayment

Premiums are due as stated on the Declarations. Failure to pay premium when due may result in cancellation of coverage in accordance with policy terms. The insurer may cancel or nonrenew the policy in accordance with the policy provisions and applicable law. Any return premium due will be calculated in accordance with the policy's earned premium provisions.

Declarations and Applicant Certification

By signing below, the applicant certifies that all statements in this application and the information provided in support of coverage are true and complete to the best of the applicant's knowledge. The applicant understands that misrepresentation or omission of material facts may void coverage and may be grounds for denial of a claim or rescission of the policy.

The applicant acknowledges receipt of the policy's terms, conditions, limitations and exclusions and agrees to comply with all policy provisions. Coverage is effective only if and when the insurer issues a policy and the premium is paid as required.

Acknowledgment of Receipt

I acknowledge that I have received a copy of the Declarations page and understand the coverages, limits, deductibles, and exclusions as presented above.

Acknowledgment: I confirm receipt and understanding.

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