N.H. Admin. Code Ins, ch. Ins 5000, pt. Ins 5001, app A
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
N.H. Admin. Code Ins, ch. Ins 5000, pt. Ins 5001, app A