Insurance WM Document

INSURANCE WM DOCUMENT

Applicant / Insured Information

Date of Birth:   Phone:   Email:

Policy Details

Coverage Amount: $   Deductible: $   Annual Premium: $

Policy Period From:   To:

Coverage Selection

Select coverages being applied for (check all that apply):

General Liability

Property Damage

Professional Liability (Errors & Omissions)

Workers' Compensation

Umbrella / Excess Liability

Beneficiary / Payee Designation

Designate primary beneficiary or loss payee for proceeds where applicable.

Prior Losses and Claims

Have you had any claims or losses in the past five (5) years?   Yes   No

Exclusions, Limitations and Acknowledgements

The following exclusions are material to this application and to any policy issued: intentional acts, criminal acts, pollution not otherwise scheduled, war and nuclear hazard, and any loss arising from fraudulent or dishonest acts by the insured. Applicant represents that no coverage is sought for excluded risks unless a specific endorsement is requested and accepted in writing by the insurer.

Applicant acknowledges that coverage will be subject to policy terms, conditions, endorsements, and any applicable limits and deductibles. Applicant further understands that acceptance of this application does not bind coverage until a policy is issued and premium payment terms are satisfied.

Declarations and Authorizations

I, the undersigned, declare that the statements contained in this application are true, complete and correctly recorded to the best of my knowledge and belief. I acknowledge that material misrepresentation, omission or concealment may result in denial of coverage, rescission of the policy, or forfeiture of benefits in accordance with applicable law.

I authorize the insurer, its agents and representatives to make such investigations and inquiries as may be necessary to determine eligibility for coverage, including but not limited to obtaining claim history, loss runs, underwriting information and other records from prior insurers, employers, medical providers and other third parties. I further authorize release of such information to reinsurers and representatives of the insurer as required for underwriting and administration of the policy.

I understand the insurer may pursue subrogation rights where applicable and that I will cooperate with reasonable requests to preserve subrogation rights. Premium payment, policy issuance, renewal and cancellation provisions shall be governed by the policy form and applicable law.

Applicant Certification

By signing below I certify under penalty of perjury that I am authorized to complete this application on behalf of the named insured and that the information contained herein is true, complete and correct. I understand this certification is a condition precedent to the issuance of a policy and that the insurer will rely upon these statements in determining whether to provide coverage and on what terms. I consent to electronic communication and records related to this application and any resulting policy if requested by the insurer.

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