This application, duly completed, together with any supplementary information must be signed in ink by the applicant. A signed copy will be attached to and becomes part of insurance policy if issued. Completion of this Application does not bind the applicant or Underwriters to complete the insurance. (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 on this application. All information disclosed on this application together with any supplementary information obtained regarding the applicant shall be considered proprietary and remain in the exclusive control of the named insured and the insurer. Mail signed and dated application to
Date _________________________ ____________________________________________________
Executive Director or Finance Director (type or print)
Complete Equity Markets, Inc.
In California dba Complete Equity Markets Insurance Agency, Inc.
1190 Flex Court
Lake Zurich, Illinois 60047
Toll Free (800) 323-6234
In Illinois (847) 541-0900
Fax (847) 541-0444
AIF 2078 AR-NP (09/08) THIS DOCUMENT MUST NOT BE DUPLICATED