Insurance MOI Form

INSURANCE MOI FORM

1. Parties and Identification

Client Name:

Contact Phone:    Email:

2. Entity Type and Producer

Entity Type: Individual Corporation LLC Trust Other

3. Policy and Insurer Details

Policy Type: Property General Liability Automobile Professional Liability Umbrella Other

4. Policy Period

Effective Date:    Expiration Date:

5. Coverage Summary

The following coverages are provided under the referenced policy subject to the terms, conditions and exclusions of the policy:

General Liability — Limit:

Property (including named perils) — Limit:

Business Automobile — Limit:

6. Exclusions and Limitations

The coverages summarized herein are subject to exclusions, conditions, endorsements and other policy provisions. Typical exclusions may include, without limitation:

• Intentional acts, fraudulent acts, or criminal conduct by insured parties;
• War, nuclear hazard, and pollution except as specifically endorsed;
• Contractual liabilities where not otherwise insured by endorsement;
• Losses excluded by specific endorsements or sub-limits stated in the policy.

Acknowledgment of Exclusions: Applicant acknowledges that exclusions and limits apply and that this Memorandum does not amend policy terms.

7. Beneficiary / Certificate Holder

8. Claims, Notices and Documentation

Loss Notice: Insured shall give prompt notice to the insurer and producer of any occurrence or claim likely to involve coverage. Failure to provide timely notice may affect coverage to the extent permitted by law.

9. Representations, Warranties and Certifications

The undersigned certifies that the information provided in this Memorandum of Insurance is complete and accurate to the best of the undersigned's knowledge. The undersigned further acknowledges that this Memorandum is issued solely as evidence of insurance coverage and does not alter, extend or waive any terms, conditions or exclusions of the referenced policy unless expressly stated in a written endorsement issued by the insurer.

Fraud Warning: Any fraudulent statements, misrepresentations, or concealment of material facts made with the intent to defraud may result in denial of coverage, rescission of the policy, or other remedies permitted by law.

10. Certification and Authorization

By signing below, the applicant authorizes the insurer and producer to release information concerning the policy identified above to the beneficiary/certificate holder named herein for the limited purpose of confirming coverage. This authorization does not permit amendment of policy terms or creation of additional insured status unless endorsed in writing by the insurer.

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