This deliverable is used when submitting an application.

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By default Policy Application deliverables print. However, a database-only setting can alter this behavior. When enabled, the deliverable will not automatically print but will have its print state set to printed. The print state is set to printed so agents may view the deliverable when the Only display printed deliverables in Policies and Claims 'Documents' page setting is also enabled. To keep Policy Application deliverables from printing, run

#UPDATE settings SET value=1 WHERE option='suppress-policy-application-print'

Settings > Deliverables > Policy Application

If you allow applications to be submitted bound, add <b>Binding Statement: This application was submitted bound</b> to the Front Text Area of the deliverable setup.


Example Wording

  • Example 1

The current Policy Application replaces all previously issued Policy Applications, if any. Each policy period of one year beginning on the policy effective date and ending on the policy expiration date constitutes the policy period.

This policy applies only to those coverages indicated below for the limit of coverage as shown and for which a premium has been charged. The limit for each coverage shall not be more than the amount stated for such coverage, subject to all the terms and conditions of this policy.

The policy Deductible reflected on this Policy Application applies to all property coverages unless otherwise stipulated within the policy language.

Binding Statement:
Notice to Applicants - As part of the Company's Underwriting Procedure, a routine credit inquiry may be made which will provide applicable information concerning your character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report if one is made, will be provided. All checks and drafts received are subject to payment by the financial institutions upon which they are drawn. No coverage shall be deemed to have been in effect from the effective date of this application for insurance if payment is refused on such check or draft tendered, or to be tendered in payment for this insurance.

WAIVER OF COAL MINE SUBSIDENCE
I (we) do not desire coal mine subsidence insurance coverage and hereby waive any right to such coverage under this policy or any future policy my (our) interest in the property described in the policy (in the application). Unless I (we) request coal mine subsidence coverage, in writing, at some future date.

  • Example 2

This Policy Application replaces all previous Policy Applications, if any.

VERY IMPORTANT: If the words "Binding Statement" do not appear immediately below, this application is being submitted to Mutual of Wausau Insurance Corporation unbound.

Binding Statement:
The policy is considered to be bound with Mutual of Wausau Insurance Corporation. This does not mean that underwriting relinquishes the right to alter this policy should a need be found in their review of this application.

CAUTION: READ CAREFULLY BEFORE SIGNING

I have read the above questions, and I hereby declare to the best of my knowledge and belief that all of the statements are true and that these statements are offered as an inducement to the company to issue the policy for which I am applying. I understand that Mutual of Wausau Insurance Corporation may perform a property survey. The property survey or any resulting advice or report does not warrant that the property or operations are safe or are in compliance with any law, rule or regulation.

In order to underwrite the insurance applied for above, I authorize Mutual of Wausau Insurance Corporation to obtain a consumer report and/or information from previous insurance carriers, regarding claim history and credit standing. You have the right to make a written request within a reasonable period of time to receive details about the nature and scope of the gathered information.

ACH Payment Authorization
To initiate ACH Payments with Mutual of Wausau, please read and sign below.

I/we authorize Mutual of Wausau Insurance Corporation to initiate debit entries for payment of premium bills each billing cycle, and if necessary, to initiate credit entries and adjustments for any debit entries in error to my bank account. This authority is to remain in force and effect until Mutual of Wausau Insurance Corporation has received written notification from me of its termination in such time and manner as to afford Mutual of Wausau Insurance Corporation and the financial institution a reasonable opportunity to act upon it.

If an ACH withdrawal attempt fails due to non-sufficient funds, we will send you, your agent and any mortgage holder a 10-day cancellation notice. A $25 service charge along with the premium due will be required as payment to prevent the policy from canceling. Only guaranteed type funds (cash, certified bank check, money order, etc.) will be accepted. Payment must be received in our office by the due date. At any time in the future, if you have a second ACH withdrawal attempt returned due to non-sufficient funds, we will send out a 10-day cancellation and will not accept payment as a means to prevent cancellation.

My signature below authorizes: (Please initial only one)
__ Initial Payment ACH
__ Future Payments ACH
__ Initial and Future Payments ACH

  • Example 3

Binding Statement: This application was submitted bound

The current Policy Application replaces all previously issued Policy Applications, if any. Each policy period of one year beginning on the policy effective date and ending on the policy expiration date constitutes the policy period.

This policy applies only to those coverages indicated below for the limit of coverage as shown and for which a premium has been charged. The limit for each coverage shall not be more than the amount stated for such coverage, subject to all the terms and conditions of this policy.

The policy Deductible reflected on this Policy Application applies to all property coverages unless otherwise stipulated within the policy language.

VERIFICATION OF CONTENT
I agree that the statements contained in this application are true to the best of my knowledge and that no material fact has been withheld. Furthermore, I agree to pay any surcharges applicable under Company rules which are necessitated by inaccurate statements. I understand that this policy may be cancelled if this application contains any false information or material misrepresentation.

FRAUD STATEMENT
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

POLICY PREMIUMS AND CHARGES
You may pay any amount from the minimum amount due to the total remaining balance. If you overpay the minimum amount due, the overpayment balance will be applied to the next billing period. Advanced payments allow you to skip subsequent payments and avoid installment fees. Billing notices will be mailed 45 days in advance of premium due dates.

I understand that if I make the initial payment or subsequent renewal payments by check, credit/debit card, electronic funds transfer, or other method of remittance and the payment is not honored by my financial institution for any reason, the Company shall be considered as not having accepted the payment and the policy will be cancelled.

I understand that if I make a payment outside of the premium due dates, acceptance of such a payment by the Company does not necessarily imply coverage by the Company.

I understand that the following charges may be assessed and the fees are separate from premium and are non-refundable. Imposition of these fees does not imply coverage. The Company reserves the right to amend the fee structure and/or amount of each fee. The Company will provide you notice of any changes prior to the effective date of the change.

A $30.00 service charge may be assessed to the balance due on your policy if any payment offered is not honored by your bank or other financial institution.

A $25.00 reinstatement fee may be assessed for any policy which is cancelled and reinstated within 30 days of the prior policy expiration date.

A $3.00 non-EFT installment fee may be assessed for each installment payment made via any method other than Electronic Funds Transfer (EFT).

A $1.00 EFT installment Fee may be assessed for each installment payment made via Electronic Funds Transfer (EFT).

A $25.00 late fee may be assessed when the minimum amount due is paid after the due date but before the policy cancellation date.

Applicant(s):__
Dated:___, 20

ANNUAL MEETING NOTICE
The insured is hereby notified that by virtue of this policy he is a member of the CARRIER NAME, and that the annual meetings of said Company are held at the Home Office on the 3rd Saturday in January of each year at 10 a.m.

REPLACEMENT COST TERMS
If applicable, the CARRIER NAME replacement cost is an estimated replacement cost based on general information about your home. It is based on models that use cost of construction materials and labor rates for like homes in the area. The actual cost to replace your home may be significantly different. CARRIER NAME does not guarantee that this figure will represent the actual cost to replace your home. You are responsible for selecting the appropriate amount of coverage and you may obtain an appraisal or contractor estimate which CARRIER NAME will consider and accept, if reasonable. Your policy may contain a coinsurance provision. This section does not modify or change in any way the terms and conditions of your policy. Please read the policy terms and conditions carefully.

INFORMATION GATHERING & CONSUMER REPORTING
I acknowledge that the Company and its affiliates may collect and use information from consumer reporting agencies, such as loss histories and credit history reports. I authorize the Company to use a credit-based insurance score based on the information contained in that credit report. This information will also be used to underwrite my insurance and to provide me an accurate quote. Furthermore, I authorize the Company to obtain future reports to update or renew the insurance or to offer replacement insurance. I also acknowledge that information about me may be disclosed without authorization, but only as permitted by law. The credit bureau used by the Company is TransUnion and may be contacted at TransUnion Consumer Solutions, P.O. Box 2000, Chester, PA 19022-2000 or by calling 1-800-916-8800. I understand that while TransUnion provided the report, they did not make the decision that affected the premium on my policy, nor would they be able to tell me the reasons why this decision was made.

HOW CAN I REVIEW AND CORRECT INFORMATION YOU HAVE ABOUT ME?
To review information we have about you, send a written request to CARRIER NAME AND ADDRESS. You must describe the kind of information you want to review. Include your full name, address, policy number (if applicable), and phone number. Within 30 business days, we will describe what is available and how you may request corrections. We will also identify anyone we show as having received the information within two years prior to your request. Finally, we will identify the companies that have provided Consumer Report Information about you. You may review the information at our office or receive a copy of it for a fee to cover our costs. We will not provide information that we feel is privileged, such as information about insurance claims or lawsuits. To correct information we have about you, send a written request as described above explaining your desired correction. Within 30 business days, we will either make the requested correction or tell you why we will not. We cannot correct Consumer Report Information, such as your credit report. To do this, you must contact the consumer reporting agency that provided it. If we make your requested correction, we will notify you and anyone named by you who may have received the information within the previous two years. If we refuse to make the requested correction, you may file with us a concise written statement about why you object, including the information you think is correct. Your statement will then become a part of your file.

I hereby apply for insurance on the property as indicated herein, against direct loss by the perils on the forms requested, subject to all the terms and conditions of the policy issued. I hereby agree that any building used or originally intended to be used in whole or in part for any farming or business purpose, and not specifically designated for use as an appurtenant or related private structure, will not be considered an appurtenant or related private structure.

Applicant(s):___

Dated:__, 20__

  • Example 4

The undersigned warrants, represents, and agrees that statements herein are made with respect to me and all members of my household for the express purpose of inducing the Company to issue an insurance policy, and these statements are true, correct, and complete to the best of my knowledge. I understand that any binder or insurance policy issued as a result of this application will be based on the facts and answers stated. I further agree that false statements given by me could make the policy issued because of this application null and void. I understand that if any premium remittance by or on my behalf is not honored by the payer (bank), it will be deemed nonpayment of premium and no coverage will be afforded.

Disclosure to Applicant pursuant to the terms of the Fair Credit Reporting Act: You are hereby notified that an investigative consumer report may be obtained by a representative of the Company. You may request in writing from the Company, disclosure of the nature and scope of such report if obtained. The undersigned authorizes the Company to perform a general investigation of the applicant(s) for purposes of this insurance coverage. The undersigned authorizes the Company to enter onto the premises for purpose of inspecting any structure for which this insurance is applicable.

By submitting this application electronically, I certify that I have the Applicant's Signature on file in my office.

BINDING STATEMENT
Pending the issue of a permanent policy, the above are the essential terms of a temporary contract for insurance with the above named company. This Coverage Binder will expire automatically when the permanent policy is issued or at 12:01am upon the expiration of thirty days (not more than 30) from the issue date, whichever comes first. This coverage binder may be terminated at any time by written notice to any of the named parties on this contract.

INSURANCE FRAUD WARNING NOTICE - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.


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