Policy Transfer Form

POLICY TRANSFER FORM

Use this form to request transfer of ownership, assignment, or change of insured interest for the policy identified below. The Transferor (current owner) and Transferee (proposed new owner) must complete the information requested. Completion of this form does not guarantee acceptance of the transfer; the insurer retains sole discretion to approve and to impose terms, conditions, or additional underwriting requirements.

1. Transfer Request — Parties

Transferor (Current Policy Owner):

Transferee (Proposed New Owner):

Individual    Corporation    Trust    Partnership

2. Existing Policy Information

Insurer Name:

Policy Number:     Policy Type:

Policy Period From:    To:

3. Transfer Terms and Coverage Selection

Requested Transfer Type: Full Policy Ownership Partial Assignment / Beneficial Interest Only Endorsement / Amendment

Property Coverage    Liability Coverage    Medical Payments    Uninsured Motorist

4. Beneficiary Designation (if applicable)

Is beneficiary information changing as part of this transfer? Yes No

5. Consideration & Effective Date

Consideration for Transfer (if any):

Requested Effective Date of Transfer:

6. Representations, Warranties and Authorization

The undersigned Transferor and Transferee each represent and warrant that all information contained in this form is true, complete and correct to the best of their knowledge; that no material facts affecting insurability have been withheld; and that no proceedings are pending which would materially affect the risk. The Transferor represents that it has the legal right to transfer the interest claimed and that there are no liens or encumbrances not disclosed below.

Authorization: The undersigned authorizes the insurer and its representatives to obtain, verify, and exchange such information as may be relevant to the consideration of this transfer, including but not limited to loss history, underwriting files, and proof of identity or legal status. The undersigned further acknowledges that insurer approval is required for completion of the transfer.

Consent to Transfer Prior Claims or Losses: I consent to transfer recorded claims/loss history with the policy I do not consent to transfer claims/loss history

7. Exclusions and Limitations

The insurer may decline, modify, or condition approval of any transfer. Transfers will not apply retroactively to losses, claims, or obligations that occurred prior to the effective date, except as expressly accepted in writing by the insurer. Policy provisions, endorsements, and exclusions in effect at the time of transfer shall continue to apply unless explicitly amended by the insurer.

Standard exclusions that may affect transfers include but are not limited to: prior known losses, misrepresentation or fraud in the original application, criminal acts by a proposed insured, and interests subject to court order or statutory restriction.

8. Required Documentation Checklist

The following documents must accompany this form. Failure to provide required documentation may delay processing or result in denial.

Original policy document or certified copy

Signed assignment or transfer agreement

Proof of identity for Transferor and Transferee

Proof of insurable interest (if required)

Trust documents or corporate resolutions (if transferee is a trust or entity)

Death certificate (if applicable)

9. Additional Remarks

10. Declaration and Applicant Signature

By signing below, the undersigned declares under penalty of perjury that the information provided in this form is true and complete. The undersigned acknowledges that knowingly making a false statement or omitting a material fact in connection with an insurance application or transfer may constitute insurance fraud and may be grounds for denial of the transfer or rescission of coverage. The undersigned further acknowledges that approval of the transfer is subject to insurer review, and that additional documentation or underwriting may be required.

Sign Now