Insurance Binder Form

An Insurance Binder Form sample form.









 

Effective Date and Hour__________________________

 

Insured__________________________________________

 

Address__________________________________________

 

Company__________________________________________

 

Premium__________________________________________

       __________________________________________

 

Coverage___________________________________________________

        ___________________________________________________

        ___________________________________________________

        ___________________________________________________

 

This binder is evidence that ___________________________has placed the described insurance with the above Company for the amount set forth.  This binder shall remain in force for ____days from the date of commencement of liability hereunder or when, if earlier, it is replaced by a policy of the Company, and is subject to all the terms and conditions of said policy as customarily issued by the Company.  This binder may be cancelled by the Insured by mailing to the Company written notice stating when thereafter such cancellation shall be effective.  This binder may be cancelled by the Company by mailing to the named insured at the address shown in this binder written notice stating when not less than ten days hereafter such cancellation shall be effective.

 

                          _______________________________

 

                          By_____________________________

 

                          Dated__________________________

 

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