Insurance Terms Agreement

INSURANCE TERMS AGREEMENT

This Insurance Terms Agreement (the Agreement) is entered into between Insurer Name: and Applicant / Insured Name: . Policy Number:

Applicant / Insured Information

Policy Details

Policy type: Term Life Whole Life Auto Homeowners Liability Commercial

Policy period: From to

Coverage Options

Select the coverages provided under this policy. Coverage is subject to the terms, conditions and limits set forth herein and in the policy schedule.

Property Damage

Bodily Injury Liability

Personal Property Coverage

Additional Named Perils (specified in schedule)

Exclusions and Limitations

The policy does not cover loss or liability arising from (a) intentional acts or willful misconduct by the Insured; (b) losses caused by nuclear hazard, war, civil commotion, or governmental seizure; (c) losses expressly excluded by endorsement; and (d) losses for which coverage is barred by statute. The Insurer’s liability shall be limited to the actual amount of loss up to the coverage amount and subject to deductible(s).

By checking the box below, the Applicant acknowledges receipt and review of the above exclusions and limitations.

Beneficiary Designation

Primary Beneficiary Name:

Relationship to Insured:

Percentage allocation:

Claims Notification and Requirements

In the event of a loss, the Insured shall notify the Insurer as soon as reasonably practicable and no later than the time periods specified in the policy schedule. The Insured must furnish a signed proof of loss, cooperate with the Insurer’s investigation, provide documentation substantiating the claim, and take reasonable steps to mitigate further loss. Failure to comply with notification and documentation requirements may result in denial or reduction of benefits.

Declarations, Warranties and Agreement

The Applicant represents, warrants, and agrees that all statements and information provided in connection with this Agreement are true, complete, and accurate to the best of the Applicant’s knowledge. The Applicant acknowledges that any material misrepresentation or omission in the application or related documents may constitute grounds for rescission or denial of coverage.

Premiums are due in accordance with the payment schedule set forth by the Insurer. Nonpayment of premium when due shall entitle the Insurer to suspend or cancel coverage in accordance with the policy terms. If coverage is cancelled, return premiums, if any, shall be computed in accordance with the policy provisions.

This Agreement, together with the policy schedule, endorsements, and any attachments, constitutes the entire agreement between the parties with respect to the subject matter hereof. Any amendment or modification must be in writing and signed by an authorized representative of the Insurer and the Applicant.

The parties agree that disputes arising under this Agreement shall be governed by applicable law and that, where permitted, disputes will be resolved in the courts of the jurisdiction specified in the policy schedule. If any provision of this Agreement is deemed unenforceable, the remaining provisions shall remain in full force and effect.

Privacy and Data Use

The Insurer is authorized to collect, use and disclose personal information necessary to underwrite the policy, administer coverage and process claims. The Applicant consents to such uses and to any disclosures to agents, reinsurers, service providers, and as required by law.

Acknowledgment and Certification

By signing below, the Applicant certifies that the information provided in this Agreement is accurate and complete. The Applicant authorizes the Insurer to rely upon the statements herein in issuing coverage. The Applicant acknowledges receipt of the policy schedule, the premium terms, and the listed exclusions.

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