Policy Renewal Application Form

Policy Renewal Application Form

Applicant / Insured Information

Current Policy Information

Policy Number:    Insurer / Company (as shown on current policy):

Requested Renewal Coverage

Select coverages requested for renewal (check all that apply):

Changes in Risk / Claims History

Have there been any claims, losses, or incidents (insured or not) since the last policy period?   Yes   No

Have there been any material changes to the insured risk (ownership, occupancy, business operations, use of premises or vehicles)?   Yes   No

Have any drivers, principals or insured parties been convicted of a moving violation, DUI, or had a license suspended in the past five years?   Yes   No

Beneficiary / Loss Payee Information (if applicable)

Beneficiary Name:   Relationship:   Percentage:

Beneficiary Name:   Relationship:   Percentage:

If additional beneficiaries, attach schedule or list here:

Exclusions, Endorsements and Notices

The insurer's policy form contains specific exclusions, conditions and endorsements that affect coverage. Common exclusions include intentional acts, wear and tear, nuclear hazard, war, and pollution unless specifically endorsed. The insurer may require inspections or remedial measures as a condition of renewal.

I acknowledge that I have reviewed the standard exclusions and understand that additional endorsements may be required for full coverage.   Acknowledged

Declaration and Authorization

I hereby apply for renewal of the policy referenced above. I declare that the statements and answers provided in this application are true, complete and correctly recorded to the best of my knowledge and belief. I understand that material misrepresentation, omission, or fraudulent statements may render coverage void or subject to rescission and may give rise to criminal or civil penalties under applicable law.

I authorize the insurer and its representatives to make any necessary inquiries to verify the information provided, including but not limited to claims history, driving records, credit information where permitted, and other underwriting sources. I understand that approval of this renewal request is subject to underwriting review and payment of any required premium or endorsement charges.

By signing below I certify that I am authorized to request renewal of the policy and agree that this application and any supplemental information provided shall form the basis of any renewal policy issued.

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