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Get Usi Affinity Wic-lpl-app-01md 2014-2024

Awan Road Suite 200 Matawan, NJ 07747 Please Return Completed Application to: Mike Mooney, Vice President Mike.Mooney@usiaffinity.com Fax – 610.537.2057 Phone – 601.537.1441 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED INSURANCE POLICY. IT IS IMPORTANT THAT YOU REPORT ANY KNOWN FACTS OR CIRCUMSTANCES THAT COULD REASONABLY BE EXPECTED TO RESULT IN A CLAIM TO YOUR CURRENT INSURER AND IF NECESSARY TO PRESERVE COVERAGE FOR SUCH CLAIM THAT YOU PURCHASE AN EXTENDED REPORTING PERIOD ENDO.

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