MBA Evidence of Insurance - Instructions - Mortgage Bankers by jizhen1947

VIEWS: 15 PAGES: 8

									                             Field
Date
Loan Number

Insured Name

Insured Address
Insured City
Insured State
Insured Zip
Property Address




Property City




Property State




Property Zip




Brief Description of the Property (including location)




Company Name




Company Address

Company City

Company State

Company ZIP



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NAIC Number



Policy Number

Code
Sub Code
Effective Date
Expiration Date
This Replaces Prior Evidence Dated




Agent Company



Agent Address

Agent City

Agent State
Agent ZIP

Agent Contact Name

Agent Phone Number

Agent Fax Number

Agent's Email

Agent Customer ID



Add'l Interest Name



Add'l Interest Address
Add'l Interest City
Add'l Interest State
Add'l Interest Zip




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Perils Insured:




Building Coverage Amount of Insurance ($):



DED:
Personal Property Coverage Amount of Insurance ($):



DED:
Blanket Coverage


Stated Margin Clause


Business Income / Rental Value
Actual Loss Sustained:
Extra Expense:
Replacement Cost

Agreed Value / Waiver of Coinsurance
Coinsurance
Terrorism Coverage

Terrorism-Specific Exclusion?
Ordinance or Law Coverage

Limited Fungus Coverage

Named Windstorm (Wind / Hail)




Flood Coverage
(If Applicable)
Equipment Breakdown (If Applicable)
Earth Movement Coverage (If Applicable)
Permission to Waive Subrogation in Favor of Mortgage Holder
Prior to Loss



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Additional Policy Information




The business and individual named below are authorized to
execute this “Evidence of Insurance” on behalf of the
insurance company issuing each policy of property insurance
described herein.




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                                       Instructions for completion
Enter the calendar date that the form is completed.
Enter the Lender/Servicers Loan Number
                                           Insured Information
"Named Insured" as shown on the policy declarations page. Where multiple insureds are listed show
the "First Named Insured" as stated on the declarations page.
Address of the "Named Insured" as shown on the policy declarations.
City of the "Named Insured" as shown on the policy declarations.
State of the "Named Insured" as shown on the policy declarations.
ZIP Code of the "Named Insured" as shown on the policy declarations.
Street address of the insured property as shown on the policy declarations or if listed on a master
policy the street address of the insured property as shown on the supplemental declarations or/if
endorsed the street address of the property as shown on the endorsement attached to and forming
part of the policy.
City where the insured property is located as shown on the policy declarations or if listed on a master
policy the City where the insured property is located as shown on the supplemental declarations or/if
endorsed the city where the property is located as shown on the endorsement attached to and
forming part of the policy.
State where the insured property is located as shown on the policy declarations or if listed on a
master policy the state where the insured property as shown on the supplemental declarations or/if
endorsed the state where the property is located as shown on the endorsement attached to and
forming part of the policy.
The postal ZIP code (zone improvement plan) for the location where the insured property is located as
shown on the policy declarations or if listed on a master policy schedule the ZIP code as shown on the
schedule or supplemental declarations or/if endorsed the ZIP code for the location as shown on the
endorsement attached to and forming part of the policy.

Please describe using plain language the use, location, construction, occupancy, protection and
neighborhood where the property is located as listed on the policy declarations page or as noted
above. For example: "100 unit apartment building consisting of 10 two story buildings constructed of
frame/wood and brick veneer. All units have individual unit keyed door locks as well as central station
alarms. The neighborhood is suburban residential."

      III. Carrier and Agent Information (If Multiple Companies or Policies, Add on Addendum)
State the complete insurance company name shown on the declarations page of the insurance policy.
Do not abbreviate the name of the insurer or use a collective reference such as "XYZ" or "The XYZ
Group", rather specifically state each insurer as "XYZ Insurance Company"

The insurance company street address as shown on the declarations page of the insurance policy.

The city where the insurance company is located as shown on the declarations page of the insurance
policy.
The state where the insurance company is located as shown on the declarations page of the insurance
policy.
The postal ZIP code (zone improvement plan) for the location where the insurer is located as shown
on the policy declarations.

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The NAIC individual company number (National Association of Insurance Commissioners) as provided
by the NAIC or other reference such as A.M.Best's (see http://www.ambests.com)

The policy number assigned by the insurer as shown on the declarations page of the insurance policy.

If applicable
If applicable
The policy effective date as shown on the declarations page of the insurance policy.
The policy expiration date as shown on the declarations page of the insurance policy.
If the policy was issued as a "replacement" policy or if the certificate is issued as a "replacement"
certificate for the same coverage enter the date the prior policy or certificate was issued. This is
important to correlate various editions of similar coverage and/or certificates.

Corporate entity issuing the certificate for whom the individual agent/broker/producer is employed.
If operating as a sole proprietor then enter full name of licensed individual under who's authority the
certificate is being issued.
Street address on file with the insurance regulatory authority in the state/territory/district where the
agent/broker/producer is located.
City on file with the insurance regulatory authority in the state/territory/district where the
agent/broker/producer is located.
State/territory/district where the agent/broker/producer is located.
The postal ZIP code (zone improvement plan) for the location of the agent/broker/producer where
the insurer is located as shown on the policy declarations.
Name of the individual within the agency/brokerage who handles the insurance policy on behalf of
the insured.
Telephone number for the individual within the agency/brokerage who handles the insurance policy
on behalf of the insured.
Telefax number for the individual in the agency/brokerage who handles the insurance policy on behalf
of the insured.
Email address of the individual within the agency/brokerage who handles the insurance policy on
behalf of the insured.
Unique customer identification number assigned to the insured (if applicable).
    IV. Additional Named Interest(s) Information (If Multiple Interests, Add in Comments Section)

If additional interests are included under the insurance policy for which the certificate is being issued
then so state and enter the complete Name of the entity as well as the interest being added, such as
"Named Insured", "Additional Insured", or other interest.
Street address or if no street address mailing address of the additional interest.
City where the entity added as an additional interest is located.
State where the additional interest entity is located.
The postal ZIP code (zone improvement plan) for the location of the additional insured interest is
located.
                                        V. Coverage Information




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Using the most current ISO causes of loss form (CP 10 10, CP 10 20, CP 10 30) note those perils that
are in force under the policy for which the evidence of insurance is being issued is being covered as
provided under one of three ISO causes of loss forms. Where non-ISO forms are used so state and
indicate which perils are not being provided. In cases where perils that would otherwise be covered
under one of the stated ISO causes of loss forms are excluded so state. In cases where perils that
would otherwise not be covered under one of the stated ISO causes of loss forms are added/endorsed
so state.
Enter the building limit for which coverage is stated on the declarations of the policy, supplemental
declarations or statement of values attached to and forming part of the policy.

Enter the building deductible in $US or if a % so state and show the %.
Enter the business personal property limit for which coverage is stated on the declarations of the
policy, supplemental declarations or statement of values attached to and forming part of the policy.

Enter the business personal property deductible in $US or if a % so state and show the %.
If coverage is on a "Blanket" basis as defined in the ISO Commercial Lines Manual Division 5 or IRMI-
Online (www.irmi.com).

Enter the percentage if a Stated Margin Clause is applicable, as defined in the IRMI-Online
(http://www.irmi.com).
Enter the limit for the Time Element coverage indicated under

Enter details if applicable.
Enter "Yes" if coverage is provided as defined under the ISO Building and Personal Property coverage
form CP 00 10 or equivalent.
If the coinsurance penalty does not apply enter "Yes".
If the coinsurance penalty is applicable enter "Yes" and show the amount.
If the perils of "Terrorism" at a minimum per federal statute are provided for all coverages so state.

If the perils of "Terrorism" as defined by federal statute are excluded state "Yes".
If coverage is provided state "Yes" and indicate the limits for each covered section if provided by the
policy.
If coverage is provided state "Yes" and indicate the limits for each covered section if provided by the
policy.
The perils of Wind/Hail are included under the ISO Basic, Broad, and Special policy forms. When the
coverage being evidenced by this certificate restricts, excludes or otherwise limits in any way the
coverage that would otherwise be provided under the ISO policy form the Agent/Broker/Producer
must so state and reflect the true extent of the restriction.

If the perils of flood are excluded or not covered under each of the ISO Basic, Broad, and Special
Causes of Loss Forms. If the policy/policies that are in force as evidenced by the certificate provide
Enter "Yes" if coverage is provided.
Enter "Yes" if coverage is provided.
Enter "Yes" if this provision is contained in the policy.

                            VI. Comments - Additional Policy Information

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In this section the Agent/Broker/Producer must disclose any restrictions that are contained in the
policy of property insurance not noted or disclosed earlier in the form. If there are special non-
standard exceptions, endorsements, waivers, warranties or other exclusions/restrictions to the
property coverage being provided it is required that the restrictions be disclosed. Materiality in this
context will be deemed to exist by the recipient of the certificate and not the issuer thus all
restrictions, exceptions, endorsements, waivers, warranties or other provisions must be reflected in
summary form in this section.




                                             Addendum
In this section the Agent/Broker/Producer must reflect the insurance program structure for property
placements that contain multiple layers and/or insurers.




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