N.H. Code Admin. R. Ins 5001 app A - STATE OF NEW HAMPSHIRE INSURANCE DEPARTMENT

INDIVIDUAL RISK FORM FILING

NAMED INSURED AND MAILING ADDRESS

INSURANCE COMPANY AND MAILING ADDRESS

Policy Number_____________________

Policy Term_______________________

REASON FOR INDIVIDUAL RISK FORM

Describe exposure(s) or any other circumstances which would necessitate the use of a form which is not filed by the insurer.

Attach revised form(s) and copy of original form indicating what revisions were made.

I HEREBY CERTIFY THAT I UNDERSTAND THAT THE COVERAGE PROVIDED FOR THIS POLICY IS NOT STANDARD.

I HEREBY CERTIFY AND I UNDERSTAND THAT THE PREMIUM CHARGE FOR THIS POLICY (ENDORSEMENT) IS NOT STANDARD.

____________________________ ______________________________

Policyholder Signature Date

____________________________

Title

The signature by the policyholder or an authorized representative of the policyholder (NOT the insurance agent) must be made after this form has been completed.

Available at https://www.nh.gov/insurance/pc/documents/individualrisk.pdf

Notes

N.H. Code Admin. R. Ins 5001 app A

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.


No prior version found.