Insurance WC & BR Document

INSURANCE WC & BR DOCUMENT

Applicant / Insured Information

Policy Details

Policy Type: Workers' Compensation (statutory) Employers' Liability General Liability Property Business Interruption Cyber Liability

Coverage Options and Limits

Employers' Liability Limit: $ per accident / $ per disease / $

Select optional endorsements to be attached (if applicable): Stop-Gap (State Fund Excess) Waiver of Subrogation Cyber Endorsement Contractual Liability

Exclusions and Limitations

The insured acknowledges that coverage shall not apply to loss, liability or expense arising from the following unless expressly endorsed:

Intentional or fraudulent acts by the insured
Punitive or exemplary damages to the extent uninsurable by law
War, invasion, hostilities or insurrection
Nuclear reaction, radiation, or radioactive contamination
Liability assumed under contract except where insurable by endorsement

Beneficiary Designation (Workers' Compensation Death Benefits)

If applicable, designate primary beneficiary for any payable death benefits under this policy:

Claims History and Loss Information

Have there been any claims, suits, or incidents in the past five (5) years that could give rise to a claim? Yes No

Documentation Checklist

Attach copies of the following documents where applicable:

Loss runs for the past five (5) years
Payroll records and classification detail
Copies of material contracts with hold-harmless or indemnity language
Written safety or return-to-work program documentation

Declarations, Representations and Authorizations

The undersigned declares that the information provided in this Insurance WC & BR Document is true, complete and accurate to the best of the undersigned's knowledge. The applicant understands and agrees that:

1. Material misstatement or omission of fact may render the contract voidable and may constitute grounds for denial of coverage or rescission. The insurer is entitled to rely on the representations herein in determining insurability and premium.

2. The insured must promptly notify the insurer of any change in exposure, including but not limited to operations, payroll, subcontracting, incorporation, ownership change, or new locations. Premium adjustment and endorsements may be applied retroactively to the effective date of change.

3. The insurer retains the right to audit payrolls, classification records and other documents that substantiate premium and exposures. Failure to cooperate with audit requests may result in policy adjustment or cancellation.

4. By signing, the applicant authorizes release of loss history and prior policy information to underwriters for the purpose of underwriting and claim administration. The applicant further authorizes any physician or provider to release medical information reasonably necessary for claim evaluation.

5. Subrogation rights: Unless expressly waived by endorsement, the insurer shall be subrogated to the rights of the insured to recover from third parties for losses paid under this policy.

6. This document does not constitute a binder, certificate of insurance, or a promise to issue coverage. Coverage, if issued, will be governed solely by the insurance policy and endorsements issued by the insurer. Coverage is subject to all terms, conditions, limitations and exclusions contained in the policy.

7. Fraud Warning: Intentional misrepresentation or concealment of a material fact in order to obtain insurance coverage may be a criminal offense and may result in denial of coverage, cancellation of policy and criminal prosecution where applicable under law.

Acknowledgment and Signature

The undersigned certifies under penalty of perjury that he or she is authorized to execute this document on behalf of the applicant and that the information provided is true and correct.

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