This application will be incorporated in its entirety into any relevant policy of
insurance where insurers have relied upon the information contained herein. Any
misrepresentations or concealment in this application for insurance will render
insurance coverage null and void at inception. Please therefore check to make sure
all questions have been fully answered and that all facts material to your insurance
have been disclosed, if necessary by a supplement to the application.
The Applicants have reviewed all parts and attachments of this application and acknowledge
that all information is true and correct and understand that this application for
insurance is based on the truth and completeness of this information. I have provided
personal information in this document and otherwise and I may in the future provide
further personal information. Some of this personal information may include, but
is not limited to, my credit information and claims history.
I authorize my broker or insurance company to collect, use and disclose any of this
personal information, subject to the law of and to my broker's or insurance company's
policy regarding personal information, for the purposes of communicating with me,
assessing my application for insurance and underwriting my policies, evaluating
claims, detecting and preventing fraud, and analyzing business results. I can confirm
that all individuals whose personal information is contained in this document have
authorized that I agree to the above on their behalf.
Signing of this form does not bind the Applicant to purchase the insurance or the
insurer to accept the risk, but is agreed that this form shall be the basis of the
contract should a policy be issued.