Insurance Updated UMPD Form

INSURANCE UPDATED UMPD FORM

Applicant / Insured Information

Date of Birth:    Telephone:    Email:

Policy Details

Insurer / Company Name:

Policy Number:    Policy Type:

Policy Period Effective Date:    Expiration Date:

Coverage Selection and Endorsements

Select the requested change to Uninsured/Underinsured Motorist Property Damage (UMPD):

Add UMPD coverage
Modify existing UMPD limits or deductible
Remove UMPD coverage

Coverage Variant: Standard UMPD    Enhanced UMPD (higher limits)

Stacking of limits permitted: Yes     No

Covered Vehicles

List each vehicle to be covered by this UMPD update. If additional vehicles, attach a separate sheet.

Exclusions and Limitations

By initialing and signing below, the applicant acknowledges that UMPD coverage is subject to the following common exclusions and limitations unless otherwise endorsed in writing by the insurer:

• Damage caused by an at-fault insured or named operator of this policy is not covered under UMPD.
• UMPD does not cover mechanical breakdown, wear and tear, deterioration, or corrosion.
• Intentional or criminal acts by the insured are excluded.
• UMPD is subject to proof of an uninsured or underinsured motorist event as defined in the policy.
• Limits shown above represent the maximum payable per occurrence and are subject to policy sublimits and aggregate limits.

I have read and understand the exclusions and limitations set forth above. Initials:

Prior Claims and Other Insurance

In the prior five years, has any insured listed on this policy filed a claim for property damage resulting from an uninsured/underinsured motorist?   Yes    No

Is there any other motor vehicle insurance that may respond to the same loss?   Yes    No

Beneficiary Designation (If Applicable)

Some settlements or recoveries related to UMPD may permit designation of a payee or beneficiary. Provide designation only if you request insurer-recorded beneficiary instructions.

Documentation Checklist

Attach copies of the following documents as applicable. Check all that are attached:

Police report for incident(s)
Photographs of damage or scene
Repair estimates or invoices
Other supporting documentation (describe below)

Declaration and Certification

I certify under penalty of law that the information provided in this Insurance Updated UMPD Form is true and complete to the best of my knowledge. I understand that any coverage change requested herein is subject to underwriting review and issuance of an endorsement by the insurer. Coverage shall be effective only upon insurer acceptance and issuance of the appropriate endorsement amending the policy.

I authorize the insurer and its representatives to obtain and use loss history, motor vehicle records, and other underwriting information necessary to effect this change. I understand that misrepresentation or omission of material information may result in denial of coverage, rescission, or adjustment of premium and coverage terms.

Acknowledgement of Premium Adjustment

I acknowledge that changes to UMPD coverage may increase or decrease my premium. Any premium adjustment will be effective on the endorsement effective date and billed or refunded in accordance with the insurer's policies.

Estimated premium change (if known):    Effective on:

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