Insurance Underwriting Document

INSURANCE UNDERWRITING DOCUMENT

Applicant / Insured Information

Entity Type: Individual Corporation LLC Partnership Trust Other

Policy Details Requested

Policy Type: Property General Liability Professional Liability Workers' Compensation Commercial Auto

Risk Description and Locations

Coverage Options Requested

Select coverages and indicate limits where applicable:

Property Coverage — Limit:

General Liability — Each Occurrence Limit:

Professional Liability — Aggregate Limit:

Umbrella / Excess — Limit:

Exclusions, Prior Losses and Claims History

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

Are there any policy exclusions requested by the applicant or known restrictions on coverage? Yes No

Risk Management Practices

Loss control measures in place: Written safety program Fire alarms/suppression Security system Employee background checks

Beneficiary Designation (if applicable)

Beneficiary 1:

Beneficiary 2 (optional):

Documentation Checklist

Please indicate which supporting documents are attached with this submission:

Prior policy declarations
Loss runs (5 years)
Financial statements
Photographs of property / operations
Certificates of inspection / compliance

Declarations, Representations and Authorization

The undersigned applicant represents and warrants that the statements, answers and information provided in this underwriting document are true and complete to the best of the applicant's knowledge and belief. The applicant understands that any material misrepresentation, omission, or concealment of fact may be grounds for denial of coverage or rescission of any policy issued. The applicant certifies that all information submitted is provided for purposes of underwriting and risk evaluation and may be relied upon by the insurer in determining eligibility, premiums and terms of coverage.

The applicant authorizes the insurer and its representatives to obtain such loss history, claims information, inspection reports, credit information and other underwriting data as reasonably necessary to evaluate this submission. The applicant further agrees to notify the insurer promptly of any material change in the information provided prior to policy inception.

The applicant acknowledges that completion of this document does not bind coverage. Coverage is effective only upon issuance of a policy or binder in accordance with the insurer's underwriting procedures.

Producer / Broker Information

Applicant Certification and Signature

By signing below, the applicant certifies that the information contained in this Insurance Underwriting Document is true, correct and complete. The applicant understands that this certification is a material part of the underwriting process and that the insurer may rely upon it in issuing a policy. The applicant further acknowledges that submission of false or misleading information may result in the denial of coverage or rescission of any policy issued.

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