Liability Insurance Quote

Liability Insurance Quote

Quote Identification

Quote Number:    Issue Date:    Valid Until:

Parties

Recitals

WHEREAS, the Insurer has prepared this written estimate of coverage, premium and terms for the Applicant based on the representations and underwriting information provided; and

WHEREAS, the Applicant seeks a binding quotation for the liability insurance coverages described herein for the period specified, subject to verification of all information and execution of the insurer's required policy documents; and

WHEREAS, this document evidences a quotation and statement of proposed terms and is not, by itself, an insurance policy or binder unless expressly stated in a separate binder or confirmation issued by the Insurer.

Scope of Coverage

The following describes the proposed scope of liability coverage. Coverage is subject to the policy form, endorsements, conditions and exclusions finalized at binding.

Coverage Summary (Itemized)

Coverage Item 1:    Limit:    Deductible:    Annual Premium:

Coverage Item 2:    Limit:    Deductible:    Annual Premium:

Coverage Item 3:    Limit:    Deductible:    Annual Premium:

Payment Terms

Total Annual Premium:

Late Payment Fee:    Administrative Fee If Not Bound Within: days

Term and Termination

Proposed Effective Date: — Proposed Expiration Date:

Either party may terminate any binding insurance contract issued pursuant to this quotation in accordance with the policy terms and applicable law. If coverage is bound, notice of cancellation or nonrenewal shall be provided in writing in accordance with the policy and statutory notice requirements. In absence of binding, this quotation automatically expires on the Valid Until date above unless extended in writing by the Insurer.

Notice Period for Cancellation by Applicant:    Notice Period for Cancellation by Insurer:

Exclusions, Conditions and Underwriting

This quotation is subject to verification of all representations, completion of required application and documents, receipt of required premiums, and any additional underwriting conditions stated above.

Confidentiality

All information exchanged in connection with this quotation, including underwriting data, risk information and pricing, shall be treated as confidential by the parties and shall not be disclosed to third parties except as required by law, regulation, or as reasonably necessary for underwriting, claims handling, reinsurance or regulatory purposes. The parties shall implement commercially reasonable measures to protect confidential information.

Governing Law

This quotation and any resulting policy shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles.

Entire Agreement; Binding Effect

This quotation constitutes the entire statement of proposed terms and supersedes all prior oral or written communications between the parties with respect to the subject matter herein. No binding coverage will be in effect until the Insurer issues and the Applicant accepts and pays for the policy or a binder is issued by the Insurer in writing.

Acceptance

To accept this quotation in whole or in part, the Applicant must sign below where indicated and return a copy to the Insurer with payment or an agreed binding instruction. Acceptance is subject to final underwriting review and issuance of the policy.

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