Insurance MPIUA Form

INSURANCE MPIUA FORM

Applicant / Insured Information

Applicant Name:

Individual Corporation LLC Partnership Other:

Contact Phone:    Email:

Tax ID / SSN:    Date of Birth (if individual):

State or Jurisdiction of Formation:

Policy Details

Professional Liability General Liability Property Cyber Liability Other:

Desired Limit(s) of Liability:    Deductible:    Estimated Annual Premium:

Policy Period Requested: From to

Coverage Options

Select optional coverages and indicate limit where applicable:

Employment Practices Liability    Limit:

Errors & Omissions (Professional)    Limit:

Data Breach / Cyber Coverage    Limit:

Exclusions and Acknowledgements

The undersigned acknowledges that the policy(ies) applied for will contain standard exclusions. Applicant confirms awareness of the following material exclusions unless expressly endorsed:

• Intentional acts, criminal acts or fraudulent conduct by insured persons.
• Claims or circumstances known to the applicant prior to inception (prior acts) unless prior acts coverage is applied and accepted.
• Pollution, war, nuclear incidents and governmental seizure, except where limited coverage applies by endorsement.
• Liability assumed under contract beyond legal liability unless specifically endorsed.

Applicant Initials (acknowledging understanding of exclusions):

Prior Insurance and Loss History

Has the applicant had insurance of the type requested in the past five (5) years?   Yes No

Beneficiary Designation (if applicable)

Primary Beneficiary Name:

Relationship:    Percentage:

Relationship:    Percentage:

Producer / Broker Information

License Number:    Broker Phone:

Declarations and Authorization

The undersigned applicant declares that the information contained in this application is true and complete to the best of the applicant's knowledge. The applicant understands and agrees that this application, including any attachments, shall form the basis of any policy issued and that the insurer may rely upon these statements in evaluating the risk. Any material misrepresentation or omission may result in denial of coverage, rescission or termination of the policy in accordance with applicable law.

The applicant authorizes the insurer and its representatives to obtain and exchange underwriting, claims, loss history and other information relevant to the underwriting or administration of the policy, including information from prior insurers, claim reporting repositories and consumer reporting agencies where permitted by law. The applicant also authorizes the release of information to reinsurers, affiliates, and service providers as necessary for policy administration.

The applicant acknowledges that coverage will not be in effect until a binder is issued or a policy is delivered and the required premium and applicable fees are paid in accordance with the insurer's terms. Premium estimates provided in this application are not a guarantee of pricing or coverage.

Fraud Warning: Where permitted by law, any person who knowingly presents false or fraudulent information in an application for insurance may be subject to civil or criminal penalties, including denial of coverage and recovery of damages.

Sign Now