Application for Supplemental Defense Policy

Application for Supplemental Defense Policy
Potential Insured Information
Application Type
Type of Property
Type of Risk
Legal Name of Insured
Physical Street Address

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Street Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person at Insured's Location

First NameLast Name
Insured's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured's Email
example@example.com
Underwriting Data
Number of Units
Year Built
Sq Ft
FEIN#
Number of Named Insured(s)
Agent Contact Information
Agency Name
Producer's Name

First NameLast Name
Producer's Email
example@example.com
Agency Street Address

Street Address

Street Address Line 2

CityState

Zip Code
Producer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Desired Effective Date

MonthDayYear
Date
Has insured been involved in any uninsured lawsuits in the past 5 years?
Have any complaints been filed in the past 5 years against the insured with any state/county/city or other governmental agency?
Have you had any uninsured claims in the past 3 years?
AOR - Agent of Record Request
Required Insurance

You are required to be insured for Commercial General Liability including Hired and Non-owned Auto Liability, Directors and Officers Liability and Worker’s Compensation. These policies must be active and in force at the time of a claim.You are required to have in place and active Directors and officers insurance at time of claim
Check here if you understand and agree:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY (IN FLORIDA, A PERSON IS GUILTY OF THE THIRD DEGREE).

The undersigned states that he/she is an authorized representative of the applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this application (and any attachments submitted with this application) are true and complete and may be relied upon by Company in quoting and issuing the policy. If any or the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder

THIS APPLICATION WILL BECOME PART OF THE POLICY
Check here if you understand and agree:
Should be Empty:

Application for Supplemental Defense Policy

Potential Insured Information

Underwriting Data

Agent Contact Information

Required Insurance