3. If the Applicant has checked b), c) or e) above and ALSO maintains a part-time private polygraphist practice, indicate the percentage of time devoted to
* If this work is undertaken, please complete the Private Investigators Section on the last page.
I hereby declare that the above statements and particulars are true, and that I have not suppressed or misstated any material facts. At the present time, I have no reason to anticipate any claim being brought against me for any act, error, or omission on my part, other than as stated above, and agree that this Proposal Form shall be the basis of the contract between me and the Underwriters and shall be deemed a part thereof.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.
Pursuant to the provisions of the Electronic Signatures in Global and National Commerce Act (E-SIGN, 2000) execution of the application form by means of typing ones name, title and date below carries the same weight and legal effect as traditional paper documents and handwritten signatures. Further, as a principal of Applicant, I confirm that I have authority to execute this application on behalf of Applicant.
A signed copy will be attached to and form part of the Policy or Endorsement/Certificate, if issued. Completion of this Proposal Form does not bind or obligate the Applicant to complete this insurance.
Data Security Breach and Client Network Infection Questionnaire
(One client or personnel/staff equals one record)
I/We agree that this application shall be the basis of the contract with the insurers.
Signing this application does not bind the applicant or the Insurers to complete the insurance, but it is agreed that this application shall be the basis thereof.