Insurance MIC Application

Insurance MIC Application

Applicant / Insured Information

Date of Birth:    Social Security / Tax ID:

Policy Details

Policy Type: Term Whole Life Mortgage Insurance Disability Other:

Payment Frequency: Monthly Quarterly Annual Other:

Policy Period Start:    Policy Period End:

Coverage Options

Select coverages to be considered under this application (coverage issuance subject to underwriting and endorsement):

Liability Coverage
Property Damage Coverage
Personal Injury Protection
Replacement Cost Endorsement
Actual Cash Value (ACV)
Flood Coverage
Theft Coverage
Business Interruption
Mortgage Insurance Coverage (MIC-specific)
Additional Endorsements:

Beneficiary Designation

Primary Beneficiary Name:

Exclusions and Limitations

The insurer will not be liable for loss or liability arising from willful misconduct, intentional acts, fraud, pre-existing damage known to the applicant and not disclosed, wear and tear, routine maintenance failures, war, nuclear hazard, or other causes specifically excluded by policy endorsements. Additional exclusions may be applied by underwriting based on risk factors disclosed in this application.

Applicant acknowledges receipt and review of the above summary of typical exclusions and hereby certifies that any material exceptions requested are disclosed below.

I acknowledge the exclusions and understand that coverage is subject to policy language and endorsements.

Existing Coverage & Prior Claims

Prior claims or losses in the past 5 years? No Yes

Underwriting Questions

Are any of the following true? Check all that apply and provide explanations where indicated.

Presence of hazardous materials on premises
Renovation or structural work planned
Property currently vacant or unoccupied
Use of premises by smokers
Property used for commercial/business purposes

Documentation Checklist

Provide copies of the following documents with this application where applicable (check when attached):

Government-issued photo ID
Prior policy declarations
Property photos / schematics
Inspection or appraisal report
Proof of income (for life/disability)
Mortgage statement (for MIC)

Declarations and Authorization

I, the applicant, declare that all statements and particulars provided in this application are true and complete to the best of my knowledge and belief. I understand that any material misrepresentation, concealment, or omission of fact may result in denial of coverage, rescission of the policy, or forfeiture of benefits.

I authorize the insurer and its authorized representatives to make any investigations and inquiries in connection with this application, including obtaining consumer reports, claims history, and relevant underwriting information from third parties. I authorize any person or entity to release such information to the insurer.

I acknowledge that coverage, if issued, will be governed by the policy terms, conditions, exclusions, and endorsements. I agree to pay the premium when due and understand that failure to pay premium may result in policy cancellation in accordance with policy terms.

I understand and agree that this application, any attachments, and any information submitted in connection with it may form the basis of the insurance contract and may be relied upon by the insurer in its underwriting decision. I further certify that I have the authority to execute this application on behalf of the insured, if applicable.

By signing below, I consent to the use of my electronic signature and acknowledge that an electronic signature is the legal equivalent of my handwritten signature for all purposes.

Applicant Certification

I certify under penalty of perjury that the information provided in this application is true, correct, and complete. I have read and understand the statements in this application and the conditions under which coverage may be issued or declined.

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