Insurance Underwriting Questionnaire

INSURANCE UNDERWRITING QUESTIONNAIRE

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Proposed Policy Details

Coverage Amount: $    Deductible: $    Annual Premium: $

Policy Period From: to

Requested Coverages (select all that apply)

Property General Liability Commercial Auto Workers' Compensation Professional Liability

Exposure and Operations

Estimated annual revenue: $    Number of employees:

Safety, Security and Loss Control

Fire alarm system installed:    Sprinkler system installed:    Security alarm / monitored:    Background checks for employees:

Loss History

Provide details for the past five years (attach loss runs if available)

Date of Loss:    Type:    Paid Amount: $

Date of Loss:    Type:    Paid Amount: $

Additional Insureds and Beneficiaries

Add Additional Insureds:    If yes, list names and relationship or interest below.

Relationship:    Percentage: %

Exclusions and Acknowledgements

Applicant acknowledges that standard exclusions may apply, including but not limited to: wear and tear, intentional acts, nuclear hazard, war and acts of terrorism, and losses excluded by endorsement. Applicant agrees that coverage is subject to terms, conditions and endorsements of the policy issued.

I acknowledge receipt of the underwriting questions and confirm that the information provided is true, accurate and complete to the best of my knowledge. I understand that any material misstatement or omission may be grounds for declination, rescission or denial of coverage.

Documentation Checklist

Please indicate which documents are attached:

Loss runs / claims history Prior policy declarations Financial statements Photographs of premises / assets Identification documents

Declarations, Authorization and Certification

By signing below, the applicant certifies that all statements and answers in this questionnaire are true and complete. Applicant authorizes the insurer, its representatives and agents to make inquiries, investigations and inspections that are necessary to evaluate the application, including but not limited to obtaining reports, verifying information with third parties, obtaining credit and loss history reports where permitted by law, and inspecting the property or operations described herein.

Applicant understands that coverage cannot be bound until all required underwriting information and premium payment terms are agreed and a policy is issued. Applicant acknowledges that submission of this questionnaire does not guarantee issuance of a policy.

Sign Now