Mich. Admin. Code R. 500.1521 - Figure 1

Current through Vol. 22-05, April 1, 2022

Rule 21. Figure 1 reads as follows:

Date Submitted: ______________________

Named Insured _____________________

Address ______________________________

Responding Company

Policy Number ________________________ Period Insured: From ______to ______

We recently received an application for auto property (circle one) insurance from the above individual. As provided for in Section 2130 of the Insurance Code of 1956, 1956 PA 218, MCL 500.2130, please supply the claim experience for the past 3 years as available. If additional space is needed, please complete on the back of this form.

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Mich. Admin. Code R. 500.1521
1981 AACS; 2021 MR 6, Eff. 3/24/2021

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