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QUESTIONS?

If you have any questions, you can contact our underwriting department at 801-304-3705 or quotes@primeis.com.

All forms listed on this site have been prepared by Prime for the exclusive use by producers and policyholders of Prime and its affiliates. These forms are provided as a general reference guide only, and they may vary from policy forms actually issued. These sample forms do not constitute or replace the actual policy forms issued to any policyholder; accordingly, we strongly recommend that you consult with your legal counsel upon receiving any insurance forms or policies from Prime.

General Application

Step 1 of 4

25%
  • A. Producer Information

  • B. General Information

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Drop files here or
    Max. file size: 256 MB.
    • Insurance company name:Coverage:Limits:Annual premium: 
    • Policy term start datePolicy term end dateTotal incurred claims 
    • Drop files here or
      Max. file size: 256 MB.
      • Drop files here or
        Max. file size: 25 MB.
        • C. Applicant Information

        • **Supplemental questions and a discussion call with the insured will be required for formal terms**
        • The “Applicant” is the party to be named as the "Insured" in any insuring contract if issued. By signing this Application, the
          Applicant for insurance hereby represents and warrants that the information provided in the Application, together with all
          supplemental information and documents provided in conjunction with the Application, is true, correct, inclusive of all relevant
          and material information necessary for the Insurer to accurately and completely assess the Application, and is not misleading
          in any way. The Applicant further represents that the Applicant understands and agrees as follows: (i) the Insurer can and will
          rely upon the Application and supplemental information provided by the Applicant, and any other relevant information, to
          assess the Applicant’s request for insurance coverage and to quote and potentially bind, price, and provide coverage; (ii) the
          Application and all supplemental information and documents provided in conjunction with the Application are warranties that
          will become a part of any coverage contract that may be issued; (iii) the submission of an Application or the payment of any
          premium does not obligate the Insurer to quote, bind, or provide insurance coverage; and (iv) in the event the Applicant has or
          does provide any false, misleading, or incomplete information in conjunction with the Application, any coverage provided will
          be deemed void from initial issuance.
          The Applicant hereby authorizes the Insurer and its agents to gather any additional information the Insurer deems necessary
          to process the Application for quoting, binding, pricing, and providing insurance coverage including, but not limited to,
          gathering information from federal, state, and industry regulatory authorities, insurers, creditors, customers, financial
          institutions, and credit rating agencies. The Insurer has no obligation to gather any information nor verify any information
          received from the Applicant or any other person or entity. The Applicant expressly authorizes the release of information
          regarding the Applicant’s losses, financial information, or any regulatory compliance issues to this Insurer in conjunction with
          consideration of the Application.
          The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a quote with a Sublimit
          of liability for certain exposures, (ii) quote certain coverages with certain activities, events, services, or waivers excluded
          from the quote, and (iii) offer several optional quotes for consideration by the Applicant for insurance coverage. In the event
          coverage is offered, such coverage will not become effective until the Insurer’s accounting office receives the required
          premium payment.
          The Applicant agrees that the Insurer and any party from whom the Insurer may request information in conjunction with the
          Application may treat the Applicant’s facsimile signature on the Application as an original signature for all purposes.
          The Applicant acknowledges that under any insuring contract issued, the following provisions will apply:
          1. A single Accident, or the accumulation of more than one Accident during the Policy Period, may cause the per Accident
          Limit and/or the annual aggregate maximum Limit of Liability to be exhausted, at which time the Insured will have no further
          benefits under the Policy.
          2. The Insured may request the Insurer to reinstate the original Limit of Liability for the remainder of the Policy period for an
          additional coverage charge, as may be calculated and offered by the Insurer. The Insurer is under no obligation to accept the
          Insured's request.
          3. The Applicant understands and agrees that the Insurer has no obligation to notify the Insured of the possibility that the
          maximum Limit of Liability may be exhausted by any Accident or combination of Accidents that may occur during the Policy
          Period. The Insured must determine if additional coverage should be purchased. The Insurer is expressly not obligated to
          make a determination about additional coverage, nor advise the Insured concerning additional coverage.
          4. The Insurer is herein released and relieved from any and all responsibility to notify the Insured of the possible reduction in
          any applicable Limit of Liability. The Insured herein assumes the sole and individual responsibility to evaluate, consider, and
          initiate a request for additional coverage or reinstatement of the annual aggregate Limit of Liability which may be exhausted by
          any single Accident or combination of Accidents during the Policy Period.
        • MM slash DD slash YYYY

        QUESTIONS?

        If you have any questions, you can contact our underwriting department at 801-304-3705 or quotes@primeis.com.

        All forms listed on this site have been prepared by Prime for the exclusive use by producers and policyholders of Prime and its affiliates. These forms are provided as a general reference guide only, and they may vary from policy forms actually issued. These sample forms do not constitute or replace the actual policy forms issued to any policyholder; accordingly, we strongly recommend that you consult with your legal counsel upon receiving any insurance forms or policies from Prime.

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        © 2023 Prime Holdings Insurance Services, Inc., all rights reserved | Privacy Policy | Legal Disclaimers

        Prime Insurance Company (“PIC”) is an unlicensed excess and surplus lines insurance company domiciled in the State of Illinois and its principal place of business is in Sandy, Utah. Full disclaimer at www.primeis.com/legal.

        This communication does not contain any assertion, representation, or statement with respect to the business of insurance or with respect to any person in the conduct of his or her insurance business, that is untrue, deceptive, or misleading, and that is known, or that by the exercise of reasonable care should be known, to be untrue, deceptive, or misleading.

        Statements made regarding insurance coverage are for general description purposes only and they do not amend, modify, supplement, or alter any insurance policy in any way, including but not limited to claims purposes, nor do they provide details regarding terms, conditions, coverage, exclusions, or services of any insurance policy. Policy eligibility is subject to underwriting qualifications and approval. Contact PRIME INSURANCE COMPANY for more information.

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