Legal Premium Disclosure Form

LEGAL PREMIUM DISCLOSURE FORM

This Legal Premium Disclosure Form (the "Form") is made and entered into on this by and between Insurer / Payor: , with principal address , and Policyholder / Client: , with principal address (each a "Party" and collectively the "Parties").

RECITALS

WHEREAS, the Policyholder has applied for insurance coverage identified by Policy Number: , covering the period from to ;

WHEREAS, the Insurer is required by applicable law and industry practice to disclose to the Policyholder the total premium, fees, taxes, financing charges (if any), and any commissions or compensation payable in connection with the policy; and

WHEREAS, the Parties desire to set forth the material terms relating to payment and disclosure of premium and related charges.

NOW, THEREFORE

In consideration of the mutual promises and covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the Parties agree as follows:

1. DEFINITIONS

For purposes of this Form, the following definitions apply: "Total Premium" means the aggregate amount payable for the insurance coverage before credits, discounts, or financing charges; "Fees" means administrative or policy fees separately charged; "Finance Charge" means any cost assessed for premium financing including interest and other charges; "Commission" means any compensation paid to an agent, broker or intermediary.

2. PREMIUM DISCLOSURE

The Insurer hereby discloses the material amounts payable in respect of the policy identified above as follows:

3. PREMIUM FINANCING (IF APPLICABLE)

The Policyholder indicates whether the premium will be paid in full at inception or financed. If financed, the Policyholder will be provided a separate premium finance agreement; the disclosures below describe the material finance terms required by law.

Premium financed: Yes No

4. COMMISSIONS AND COMPENSATION

The Insurer or its agents disclose the following compensation arrangements directly related to the policy: commission payable to intermediary (percentage or fixed):

Any additional broker, administration, or placement fees payable by the Policyholder are identified as follows:

5. PAYMENT AND BILLING

Payment method (select all that apply):

Check / Money Order Credit/Debit Card ACH / Bank Draft Cash

6. REPRESENTATIONS, ACKNOWLEDGMENTS AND CONSENT

The Policyholder represents and warrants that all information provided to the Insurer for purposes of premium calculation and billing is true and complete. The Policyholder acknowledges receipt of the premium disclosures contained in this Form and consents to the payment arrangements checked above. The Policyholder further acknowledges that financing terms, if any, will be governed by a separate premium finance agreement.

Policyholder acknowledgement: I acknowledge that I have received and reviewed this disclosure and understand the amounts and terms identified herein.

7. CANCELLATION, REFUNDS AND ADJUSTMENTS

Premium adjustments, refunds and return premiums will be calculated in accordance with the terms of the policy and the Insurer's customary short rate or pro rata calculations, subject to any fees stated above. Any refund due will be applied first to outstanding financing obligations related to the premium before being remitted to the Policyholder, unless otherwise required by applicable law.

8. CONFIDENTIALITY

The Parties agree that non-public information contained in this Form is confidential and shall be handled in accordance with applicable privacy laws and contractual obligations, except as necessary to effectuate billing, premium financing, regulatory reporting, or as otherwise required by law.

9. NOTICES

All notices under this Form shall be in writing and delivered to the addresses below by certified mail, overnight courier, personal delivery, or other method providing proof of delivery:

10. AMENDMENT, WAIVER AND COUNTERPARTS

No amendment, modification or waiver of this Form shall be effective unless made in writing and signed by both Parties. Failure to enforce any right or remedy shall not operate as a waiver. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

11. GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the state of without regard to principles of conflict of laws.

12. ENTIRE AGREEMENT

This Form, together with any referenced premium finance agreement and the policy documents, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral, relating thereto.

13. SEVERABILITY

If any provision of this Form is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired.

14. CERTIFICATION

Each Party certifies that the person signing below is authorized to execute this Form on behalf of the respective Party and that the Party has received a copy of this Form containing the disclosures required hereunder.

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