Insurance Warranty Statement

INSURANCE WARRANTY STATEMENT

Insurer:    Policy Number:

Insured / Applicant Information

Policy Details

Policy Type: Property Liability Auto Other

Policy Period: From to

Warranties and Representations

The undersigned insured warrants and represents the following as conditions precedent to coverage. Each warranty is material to the risk underwritten by the insurer and breach of any warranty shall entitle the insurer to the remedies provided herein, including but not limited to refusal of coverage, rescission of the policy, denial of claims, and adjustment of premium retroactively.

1. Occupancy and Use: The insured warrants that the insured property located at is used for the following purpose(s): . Any material change in occupancy or use must be reported immediately.

2. Maintenance and Safety: The insured warrants that the property is maintained in a reasonable state of repair, free from known hazards, and that all safety systems listed below are functional and maintained in accordance with manufacturer and regulatory requirements.

3. Prior Losses: The insured represents that all material prior losses, claims, and incidents affecting the insured risk have been fully disclosed. If prior losses exist, describe each loss, date of loss, and disposition in the space below.

4. Alterations and Improvements: The insured warrants that no material structural alteration, renovation, or change in construction has been made without prior written notice to and acceptance by the insurer. Describe recent alterations (if any):

5. Compliance with Law: The insured warrants compliance with all applicable building codes, safety regulations, and licensing requirements. The insured will provide certificates, permits, or inspection reports upon request.

Coverage Options and Acknowledgments

Select coverages and additional endorsements that apply to this warranty statement:

Exclusions and Limitations

The insured acknowledges that the policy excludes coverage for losses arising from, among other things, intentional acts, war, nuclear hazard, wear and tear, gradual deterioration, mechanical breakdown, illegal activity, and any loss caused by failure to maintain the insured premises. The insured further acknowledges that breach of any warranty may void coverage for related losses.

Beneficiary Designation

Beneficiary designated to receive proceeds or return premiums in the event of insured's death or as otherwise specified under the policy:

Documentation Checklist

Attach or provide copies of the following documents as applicable. Check boxes to indicate documents submitted with this warranty statement:

Declaration and Certification

I, the undersigned, declare under penalty of perjury that the information provided in this Insurance Warranty Statement is true, complete, and accurate to the best of my knowledge. I acknowledge that these statements are warranties and that any material misrepresentation or failure to disclose facts material to the risk may result in denial of coverage, rescission of the policy, or other remedies permitted by law. I further acknowledge my continuing duty to notify the insurer promptly of any material change in risk.

I authorize the insurer to make inspections, obtain reports, and verify any statements contained herein. I agree that this Warranty Statement shall be incorporated into and form part of the policy to which it relates.

Sign Now