In the event that a claim or claims or any circumstance, act, error, omission or personal injury that could result in a claim against the Organization or the persons named in the application have been reported to Underwriters or disclosed on the application, or if the Organization's practice includes civil matters, Underwriters reserve the right to individually rate insurance for the above Organization.
The undersigned declares that based upon his knowledge and upon reasonable investigation, the above statements and particulars are true and complete, and that no material facts have been suppressed or misstated. The undersigned acknowledges that this Application shall be the basis of the contract with Underwriters, and that the insurance applied for will issue on the 1st day of the month following receipt of the premium and acceptance of the application by the insurer.
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.