NAIC Insurance Application

NAIC Insurance Application

This Insurance Application (the "Application") is made effective as of by Applicant Name: with principal address: (hereinafter "Applicant") and Insurer Name: with address: (hereinafter "Insurer").

RECITALS

WHEREAS, Applicant seeks insurance coverage for the operations, activities, and risks described in this Application and in any attachments submitted in connection herewith; and

WHEREAS, Insurer is willing to consider issuing a policy of insurance subject to the terms, conditions, exclusions, and limits set forth in any policy or binder subsequently issued and contingent upon Insurer's underwriting, investigation, and receipt of satisfactory information; and

WHEREAS, Applicant understands that coverage will be afforded only if and when Insurer issues an effective policy or binder and that this Application is a material part of the insurance contract if issued.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

The following definitions apply throughout this Application and any resulting policy: "Application" means this document and all attachments; "Applicant" means the entity identified above seeking insurance; "Insurer" means the underwriting company identified above. Terms not defined herein shall have the meanings given in any issued policy.

2. APPLICANT INFORMATION

Corporation LLC Partnership Individual

3. COVERAGE REQUESTED

Coverage requested (select all applicable): General Liability Professional Liability Property Workers' Compensation

Proposed Policy Period: From to .

4. PRIOR INSURANCE

5. CLAIMS AND LOSSES

Has Applicant or any proposed insured had any claim or suit in the last five years? Yes No

6. REPRESENTATIONS, WARRANTIES AND AUTHORIZATION

Applicant represents and warrants that the information contained in this Application, including all attachments and statements made to Insurer or Insurer's representatives, is true, accurate and complete to the best of Applicant's knowledge. Applicant affirms that no material facts have been withheld or misrepresented and acknowledges that such facts may be relied upon by Insurer in determining whether to issue insurance and on what terms.

Applicant authorizes Insurer and its representatives to make any investigation and inquiry in connection with this Application, including but not limited to obtaining claims, loss, credit, financial, and underwriting information from prior insurers, administrators, or other entities. Applicant authorizes the release of such information and agrees that a photocopy of this authorization shall be valid as the original.

7. FRAUD WARNING & CERTIFICATION

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in this Application may be subject to civil and criminal penalties under applicable law. Applicant certifies that the statements in this Application are true, complete, and correctly recorded.

8. NOTICES

9. AMENDMENTS, WAIVER, COUNTERPARTS

No amendment, modification, or waiver of any provision of this Application shall be effective unless executed in writing by both Applicant and Insurer. No waiver by either party of any breach shall be deemed a waiver of any subsequent breach. This Application may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

10. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

This Application and any policy issued in connection herewith shall be governed by the substantive law selected by Insurer in the policy declarations or, if no selection is made, by the law of the state of incorporation of Insurer. This Application, together with any attachments and any policy subsequently issued, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations, and agreements. If any provision of this Application is determined to be invalid or unenforceable, such provision shall be severed and the remaining provisions shall remain in full force and effect.

11. INSPECTION

Applicant agrees that Insurer or its authorized representative may inspect Applicant's premises, operations, and records as reasonably necessary for underwriting, loss control, or claims investigation, subject to prior notice and the Applicant's reasonable security and confidentiality requirements.

12. SIGNATURES

The undersigned, being authorized representatives of Applicant and Insurer, each respectively certify that they have read the foregoing statements and that the information contained herein and in any attachments is true, complete, and made for the purpose of inducing Insurer to issue the insurance requested.

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