Insurance MPIUA Application

INSURANCE MPIUA APPLICATION

Applicant Information

Date of Birth:

Policy Details

Policy Period From:   To:

Coverage Selections

Please indicate the coverages requested. Selection does not bind coverage until accepted and issued by the insurer.

Exclusions and Acknowledgment

The applicant acknowledges that the policy, if issued, will contain standard exclusions including, but not limited to: intentional acts, war or military action, nuclear hazard, wear and tear, gradual deterioration, loss caused by pollution or mold except where specifically endorsed, and business pursuits not disclosed to the insurer. Additional exclusions may apply by endorsement.

Initials acknowledging review of exclusions:

Prior Losses / Claims

Have you had any claims or losses in the past five (5) years? Yes No

Supporting Documentation Checklist

Please attach copies of the following documents as applicable. Submission of documentation may be required prior to binding of coverage.

Beneficiary Designation

Declarations and Authorizations

I hereby apply for insurance coverage as set forth in this application. I represent that all statements and particulars contained herein are true, complete and correctly recorded to the best of my knowledge and belief. I understand that any material misrepresentation, omission or incorrect statement in this application may give the insurer grounds for rescission, denial of coverage or denial of a claim.

I authorize the insurer and its representatives to obtain and verify information from third parties, including but not limited to, claims history, credit information, loss history, and other underwriting sources as necessary to evaluate this application. I further authorize third parties to disclose such information to the insurer. A photographic or electronic copy of this authorization shall be as valid as the original.

I understand and agree that coverage is not binding until a policy has been issued and the required premium and any applicable fees have been received and accepted by the insurer or its authorized representative. I acknowledge that any binder issued prior to the full underwriting review is subject to modification, endorsement, or cancellation in accordance with policy terms and applicable law.

Fraud Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud and subject to criminal and civil penalties as provided by law.

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