NOTICE TO APPLICANT:
I/We declare that the information contained herein is true and that it shall be the basis of the insurance and deemed incorporated therein, should the Underwriters evidence its acceptance of this application by issuance of coverage. I/We hereby authorize the release of claim information from any prior insurer to Underwriters.
NOTE: In applying for coverage, the Applicant agrees that in the event of covered losses, the Applicant will be required to be defended by the Underwriters' appointed lawyers, and that the deductible shall apply to loss and claim expenses, adjusting expenses, investigation costs and legal fees. If the Applicant elects to handle a claim without in any way involving the Underwriters, then no coverage for such claim is afforded the Applicant under the insurance.
IMPORTANT: Underwriters reserve the right to individually rate insurance for the above Applicant based upon the Applicant's experience. I understand and accept that the insurance applied for provides coverage on a CLAIMS MADE basis for ONLY THOSE CLAIMS MADE AGAINST THE INSURED WHILE THE INSURANCE IS IN FORCE and that coverage ceases with the termination of the insurance unless I exercise options available and in accordance with terms of the policy.
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.