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AGENCY CUSTOMER ID: PROPERTY SECTION DATE …

applicant (first named insured) effective date expiration date payment plan audit agency bill direct bill for company use only agency customer id: page 2 of 2 any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or

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A named insured's impetus for providing additional insured status to others may be a desire to protect the other party because of a close relationship with that party (e.g., wanting to protect church members performing services for the insured church) or to comply with a contractual

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AGENT/BROKER OF RECORD CHANGE DATE (MM/DD/YYYY) …

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NAMED INSURED EFFECTIVE EXPIRATION LINE OF BUSINESS POLICY NUMBER(S) (AS IT APPEARS ON POLICY) DATE DATE Please be advised that we wish to name PRODUCER as our exclusive representative effective CODE # DATE for the lines of business shown above, currently in force or submitted by application.

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named. Name of Business entity Type of entity (Corporation, Partnership, Charity, etc.) Permanent address - Street City State ZIP Phone number Tax ID number Option E - Insured’s estate You may select the Insured’s estate as either a Primary or Contingent Beneficiary. If you select the Insured’s

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Insured named above all proceeds of the Policy and/or rider(s) covering the Insured be paid to the beneficiary(ies) as shown above. X _____ X _____ Signature of Policyowner Date Signature of all current Irrevocable Primary Beneficiary(ies) ...

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How Your Accounts are Federally Insured Brochure

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Insured's death, or if the Company receives satisfactory written evidence that the Trust is not in effect, payment will be made as if the Trust was not named as a Beneficiary. - Before making payment to any Trust, the Company reserves the right to require satisfactory written evidence that

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• If the Insured resides in Massachusetts, their signature must be witnessed by a disinterested person over age 18 who is not being named as Beneficiary. My signature below indicates that I have read and agree to the terms and General provisions included with this form. Owner - First name Middle name Last name Signature of Owner

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Insured Name: Policy Number Effective Date

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515A. EXCLUSION OF NAMED DRIVER AND PARTIAL REJECTION OF COVERAGES. Policy Number: Effective Date: Insured Name: (The information above is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement forms a part of the policy to which attached, effective from its date of issue unless otherwise stated ...

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Information” section. Your named contact person will be permitted to make changes to the application paperwork on your behalf and we will communicate directly with them regarding any application issues or deficiencies. You will not be copied by the division with the correspondence.

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