Insurance LPR Forms

LENDER'S LOSS PAYABLE / LOSS PAYEE (LPR) FORM

Insured / Applicant Information

Insured Name:

Date of Birth:    Phone:    Email:

Lender / Loss Payee / Mortgagee Information

Payee / Lienholder Name:

Contact Person:    Phone:    Account / Loan #:

Policy Details

Insurance Company:

Policy Number:    Policy Type:

Coverage Amount (Limit): $    Deductible: $    Annual Premium: $

Policy Period: From to

Coverages (Select applicable)

Building / Structure Coverage

Personal Property / Contents Coverage

Business Interruption / Extra Expense

Liability Coverage (General / Premises)

Loss Payable / Mortgagee Clause

It is agreed that any loss payable under the policy shall be paid to the Loss Payee / Mortgagee named herein as its interests may appear. Such payment shall not prejudice the rights of the insurer with respect to the insured or the Loss Payee. The insurer shall provide the Loss Payee with written notice prior to cancellation or nonrenewal in accordance with the policy terms and applicable law.

The Loss Payee shall be protected for the interest of the Loss Payee only and subject to all the terms of the policy. The Loss Payee will be entitled to receive loss settlement proceeds only up to the outstanding indebtedness or insurable interest verified at the time of loss.

Exclusions / Limitations (standard)

The following are standard exclusions or limitations under this designation unless specifically endorsed to the contrary: flood and surface water damage, earthquake and earth movement, war and nuclear hazard, intentional acts by the insured, wear and tear and gradual deterioration. Additional exclusions may be set forth in the underlying policy.

Property / Collateral Description

Beneficiary / Payee Allocation

Beneficiary Name:

Relationship to Insured:    Percentage of Proceeds:

Claims / Notification Procedures

In the event of loss, the insured shall immediately notify the insurer and the Loss Payee of the loss and take all reasonable steps to protect the property from further damage. Failure to provide timely notice may affect coverage to the extent permitted by law.

Documentation Checklist

Copy of policy declarations page

Current loan or mortgage statement showing balance

Photo inventory or schedule of covered property

Declaration and Certification

By signing below, the Insured certifies that the information provided on this Lender's Loss Payable / Loss Payee (LPR) Form is true and complete to the best of the Insured's knowledge. The Insured authorizes the insurer to add the named Loss Payee to the referenced policy for the purposes described herein. This designation does not alter the terms, conditions, endorsements or exclusions of the underlying insurance policy except as expressly stated in a written endorsement issued by the insurer.

The Loss Payee acknowledges that payment of any claim will be made in accordance with the policy provisions and that the Loss Payee's recovery is limited to the outstanding insurable interest as verified at the time of loss. The Loss Payee agrees to cooperate with the insurer and the insured in the investigation and adjustment of claims.

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