Insurance User Agreement

INSURANCE USER AGREEMENT

Parties and Effective Date

Insurer Name:     Policy Number:

Client Name:     Effective Date:

Applicant / Insured Information

Policy Details

Policy Period From:    To:

Coverage Selection

Select coverage options applicable to this policy (check applicable boxes). For each selected coverage, specify limits where required.

Liability Coverage    Limit:

Collision Coverage    Limit/Deductible:

Comprehensive Coverage    Limit/Deductible:

Uninsured/Underinsured Motorist Coverage    Limit:

Medical Payments Coverage    Limit:

Exclusions

The following exclusions are material terms of the policy and constitute circumstances in which coverage will not be provided unless otherwise expressly agreed in writing.

Loss or damage arising from intentional or criminal acts by the insured.

Wear and tear, gradual deterioration, mechanical breakdown, or latent defect.

War, hostilities, insurrection, nuclear reaction, or acts of terrorism subject to policy definitions.

Beneficiary Designation

The insured hereby designates the following beneficiary for policy proceeds where applicable.

Claims Notice and Documentation

Police report (if applicable)

Photographs of damage or scene

Repair or replacement estimate

Medical records (if bodily injury)

Declarations, Authorizations and Consents

By signing this Insurance User Agreement, the insured certifies that all information provided in this form is true, complete and accurate to the best of the insured's knowledge. The insured acknowledges receipt of policy terms, conditions, exclusions, and endorsements incorporated by reference in the insurance contract.

The insured authorizes the insurer and its agents to obtain, use and disclose personal and claims-related information as necessary to administer coverage, investigate and settle claims, and to comply with applicable law. This authorization includes access to medical records, repair estimates, and third-party loss information where permitted by law.

Payment Authorization: The insured authorizes periodic premium debits or invoicing in accordance with the policy terms. The insured agrees that failure to timely pay premiums may result in lapse or termination of coverage in accordance with the policy.

Electronic Communications and Records

The insured consents to receive notices, policy documents, billing statements, and other communications electronically at the email address provided above unless otherwise required in writing. Electronic delivery of documents constitutes delivery for all purposes and retains the same force and effect as paper documents.

I consent to receive electronic communications and electronic delivery of policy documents and notices.

Data Privacy and Third-Party Sharing

The insurer may share information with reinsurers, claim investigators, service providers, and as required by law. The insured may request access to, correction of, or restrictions on certain personal information as provided by applicable law and policy procedures.

I acknowledge the data privacy and third-party sharing provisions set forth above.

Termination and Amendment

This agreement remains in force for the term of the policy and may be amended only by written endorsement signed by an authorized representative of the insurer. The insurer may terminate or non-renew coverage in accordance with policy provisions and applicable law.

Representations and Warranty; Indemnity

The insured represents that no material fact has been omitted or misstated in applying for coverage. The insured will indemnify and hold harmless the insurer from any claim arising from intentionally false statements or fraudulent acts by the insured in connection with the policy.

Acknowledgment and Certification

The undersigned certifies under penalty of perjury that the information provided on this form is true and correct. The undersigned further acknowledges receipt of a true and complete copy of this Insurance User Agreement and any policy documents delivered electronically or otherwise.

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