Insurance Underwriting Application

INSURANCE UNDERWRITING APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Corporation LLC Partnership Other

Policy Details

Property General Liability Professional Liability Commercial Auto Workers' Compensation Inland Marine Other

Risk & Property Details

Construction Type: Masonry Frame Mixed Steel/Concrete Other

Automatic Sprinkler System Central Station Alarm Fire Extinguishers Security Patrol Other

Has the applicant had any claims, losses or incidents in the past five (5) years? Yes No

Coverage Selection

Property Coverage — Limit: General Liability — Limit: Professional Liability — Limit: Business Interruption — Limit: Medical Payments — Limit:

Exclusions & Restrictions

The following exclusions are standard and will apply unless otherwise agreed in writing: losses caused by intentional acts, wear and tear, nuclear hazard, war, pollution not caused by a covered peril, and any loss expressly excluded in the policy schedule. Coverage for flood and earthquake is not provided unless specifically endorsed.

Beneficiary Designation

Designate beneficiaries for policy proceeds if applicable. Total percentage must equal 100% for all named beneficiaries.

Declarations, Authorizations & Certifications

Representations and Warranties: The undersigned Applicant represents and warrants that all statements made in this application are true and complete to the best of Applicant's knowledge and material to the underwriting decision. Applicant acknowledges that coverage will be issued, if at all, in reliance upon these statements.

Authorization to Obtain Information: Applicant authorizes the insurer, its agents and representatives to obtain underwriting information, claim history, credit information and other relevant records from third parties, including but not limited to prior insurers, claims databases, and consumer reporting agencies, as necessary to evaluate this application. Applicant also authorizes disclosure of underwriting and claim information to reinsurers and other parties involved in risk transfer.

Fraud Warning: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive material information may be guilty of insurance fraud under applicable law. Applicant certifies that no information provided herein is false, misleading, or omitted with the intent to defraud.

Premium and Cancellation: Applicant understands that issuance of a policy is subject to acceptance of premiums and that the insurer may modify terms, endorsements, or cancel coverage in accordance with the policy form and applicable law. Payment of any premium does not bind the insurer to provide coverage beyond the period for which the premium is accepted.

Indemnity and Cooperation: Applicant agrees to cooperate with the insurer in any investigation of claims or underwriting matters and to indemnify the insurer for any loss caused by intentional misrepresentations as permitted by law.

Applicant Attestation: I hereby declare that I have read and understand the statements, representations and authorizations contained in this application. I attest that all information provided is true, accurate and complete. I understand that misrepresentation or omission of material facts may result in denial of coverage, rescission of the policy, or other remedies allowed by law.

Applicant Attests: The information provided in this application is true and complete.

Applicant Authorizes: The insurer to obtain and share underwriting, claim, and credit information as described above.

Additional Information & Attachments

Prior policy declarations Loss runs (5 years) Financial statements Photos of premises/equipment Other

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