Insurance Underwriting Policy

INSURANCE UNDERWRITING POLICY

1. Insured / Applicant Information

Insured Name:

Date of Birth:    Phone:    Email:

2. Policy Details

Policy Number:    Policy Type:

Policy Period — Effective Date:    Expiration Date:

3. Coverages Selected

The following coverages are included in the underwriting determination. Select all applicable:

Commercial Property — coverage for buildings, contents and business personal property

General Liability — bodily injury and property damage liability

Business Interruption — loss of income and extra expenses

Cyber Liability — privacy breach and restoration expenses

Commercial Auto — owned, hired and non-owned auto exposures

Crime/Fidelity — employee dishonesty and related exposures

4. Exclusions and Limitations

The policy will contain, at minimum, the exclusions and limitations described below. Any additional exclusions required by the underwriter must be appended as an endorsement and initialed by the insured where indicated.

5. Underwriting Information and Risk Assessment

Construction Type:    Protection Measures:

Prior Carrier(s):    Years of Continuous Coverage:

Estimated Exposure (e.g. annual revenue, payroll):

Loss Frequency (past 5 years):

6. Documentation Checklist

Required underwriting documents received and reviewed:

Declarations page(s) from prior policy(ies)

Financial statements (as provided)

Photographs / inspection reports

Loss runs for most recent 5-year period

Risk control / safety programs documentation

7. Underwriting Determination

Underwriter determination (select one):

Accept — issue policy as applied for

Accept with conditions — approval subject to endorsements, higher deductible, or other conditions

Decline — risk not acceptable for placement

8. Beneficiary Designation (if applicable)

Beneficiaries designated under policy proceeds (if applicable). Percentages must total 100% when required by policy terms.

Relationship:    Percentage:

Relationship:    Percentage:

9. Representations, Warranties and Conditions

The insured represents and warrants that all statements and information supplied to the insurer in connection with this application and underwriting process are complete and accurate to the best of the insured's knowledge. Material misrepresentation, omission, or failure to disclose facts material to the risk may render coverage voidable or permit the insurer to rescind the policy in accordance with applicable law.

Coverage will not be effective until the insurer has approved this underwriting policy and the insurer's conditions precedent to coverage have been satisfied. The insurer reserves the right to require additional documentation, inspections, or risk management measures as conditions of issuance.

10. Confidentiality and Use of Information

Information provided in this underwriting record will be used by the insurer for risk evaluation, rating, issuance of policy documents, and claims handling. The insurer will treat submitted information in a confidential manner, subject to legal and regulatory obligations and disclosures required for underwriting and reinsurance placement.

11. Certification by Applicant

By signing below, the applicant certifies that the foregoing statements, answers and attached documents are true and complete, and that the applicant understands that the insurer will rely upon this information in determining whether to issue insurance and upon what terms. The applicant agrees to notify the insurer promptly of any material change in the facts or circumstances described in this application.

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