Application (RTP)

Are you ready to start saving money on every parcel that you insure? By completing a "U-PIC Request to Provide", you are on your way to big savings and great service. Sign up to become a U-PIC client today! Purchasing for a single package only? You do NOT need to complete this form! Instead visit the Buy Online  page. This form is to apply for volume pricing only.

INSTRUCTIONS

To become a U-PIC client, please provide the information listed below. Upon submittal, a U-PIC representative will contact you shortly.

About You
Company Name:
Address:
City:
State:
Zip Code:
Title:
Contact name:
Phone:
Fax:
Email Address:
Shipping Info
Packages Shipped Per Month:
Packages Insured Per Month:
Maximum Value Per Package: $
Average Value Per Package: $
Commodity Shipped (please be specific):
Do you ship internationally ?
Shipping Software:





Others:
Start Date: (would like coverage to begin on*)
  mm/dd/yyyy
*U-PIC does not guarantee that a policy will be issued or that this Start Date can be met.
Carriers (Choose all that apply.)
Claim History (A 2 year Claim history required for coverage)
How many claims in last 2 years:
Total dollar value of claims in last 2 years: $
Comments
Please tell us how you heard about us : AUCBYTE
Agreement
  1. Understand the terms of this coverage and acknowledge receipt of a sample copy of the policy (Evidence of Insurance). Please pay special attention to #3(b) as it pertains to packaging.
  2. Agree to pay each month's insurance premium before the 10th of the following month.
  3. Will correctly report all parcels shipped by the carrier(s) during the period of this coverage, and agree that Underwriter reserves the right to audit all reports.
  4. Understand that this policy does not cover a carrier's automatic coverage, if any.
  5. Certify that the information I have provided to compute my rate of premium was accurate and complete.
  6. Understand that I must keep a declared value report to be sent in with my premium check monthly.
  7. When using the USPS for shipping, I agree to submit all claims within 90 days of shipment date or my claims will be denied.
Terms

By signing below, you irrevocably agree to all of the terms and conditions of this agreement. Please note, your acceptance of and compliance with the terms and conditions of this agreement are a condition of your right to use U-PIC provided package insurance. Using U-PIC provided package insurance affirms your acceptance of this agreement and all terms and conditions.

___________________________________
Signature

Any person who knowingly and with intent to defraud any insurance company or other persons, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties.

Sign & fax to (818) 971-3329
or mail to:
U-PIC™ Insurance Services
5703 Corsa Avenue
2nd Floor
Westlake Village, CA 91362