UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF MICHIGAN
IN RE: Case No.: Chapter 7 Debtor(s)
ASSET PROTECTION REPORT Pursuant to Local Bankruptcy Rule 1007-2(c), debtors filing Chapter 7 petitions and debtors in cases converting to Chapter 7 must file an Asset Protection Report giving information about the status of insurance coverage on assets in the estate. The back of this page shall be completed with the following information: (1) description of the asset and location; (2) the debtor's insurance agent for the asset, or if none, the insurance underwriter; (3) the policy limit of the policy with respect to the asset; (4) the expiration date of the policy and (5) if the asset is secured, the name of the secured party and whether the debtor insures the interest of that party. If the debtor has sufficient insurance coverages to protect any exemptible interest in real or personal property or does not want the trustee of the estate to use estate funds to procure such coverages, the debtor(s) may sign the waiver below. Debtors are requested to provide the trustee with copies of all insurance policies and/or declarations representing each insurable asset with fifteen (15) days of the filing of the petition.
REQUEST TO TRUSTEE NOT TO INSURE EXEMPTIBLE ASSETS I(we) declare, under penalty of perjury, I(we) intend to provide insurance protection for any exemptible interests in real or personal property in this estate, and I request that the trustee not expend estate funds to procure insurance coverage for my exemptible assets.
Date: Debtor At:
Date: Joint Debtor (if any) At:
Type of Asset Real Property
(Include any property in which the debtor has an interest, including leased property if the lease requires the debtor to maintain insurance coverages)
Description & Location
Name & Address of Insurance Agent or Underwriter
Policy Limit and Expiration Date
Secured Parties Do you insure their interest?
1. Household Goods 2. Motor Vehicles
3. Boats, Motors, Snowmobiles, etc.
5. Equipment & Fixtures
7. Misc. Other Property
Date: Debtor Joint Debtor (if any)