IMPORTANT!
In the event that a claim or claims or any circumstance, act, error, omission or inquiry that could result in a claim against the Organization or the persons named in this application have been reported to Underwriters or disclosed on this application, or if the Organization charges fees for its services, or if the Organization does not utilize income eligibility guidelines for clients, Underwriters reserve the right to individually rate insurance for the above Organization.
It is understood that the insurance applied for will issue on the 1st day of the month following receipt of the premium and the acceptance of the application by Underwriters. I/We hereby declare, based upon my/our knowledge and upon reasonable investigation, the above statements are true and that I/We have not suppressed or misstated any material facts and this application shall be the basis of the contract with Underwriters at Lloyd's, London.