Number of security per:
Please list any other entities Member is requesting to be added as Additional Insured
FRAUD STATEMENT: Any person who knowingly and with the intent to defraud any insurance company or other person, files an application for insurance or statement of claim 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.
The Member hereby certifies, based upon reasonable and diligent investigation and to the best of the knowledge of the Member, its owners, officers, employees and representatives, that with respect to the insured operation(s) and location(s) for which this application is being submitted:
WARRANT: THE UNDERSIGNED REPRESENTS AND WARRANTS, TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, BASED ON REASONABLE INQUIRY, THAT THE PARTICULARS AND STATEMENTS SET FORTH ON THIS APPLICATION ARE TRUE, CORRECT AND ENTIRELY COMPLETE, AND THERE ARE NO OTHER RISK FACTORS THAT HAVE NOT BEEN DISCLOSED HEREIN. IF ANY PARTICULARS OR STATEMENTS ARE MATERIALLY MISREPRESENTED OR MATERIAL INFORMATION HAS BEEN OMITTED INTENTIONALLY OR ACCIDENTALLY, SUCH MISREPRESENTATION OR OMISSION WILL VOID ANY ISSUED COVERAGES AND THE INSURANCE COMPANY WILL HAVE NO DUTY TO DEFEND ANY CLAIMS, PAY ANY DAMAGES, OR PAY SUMS OR PERFORM ACTS OR SERVICES. THE UNDERSIGNED AGREES AND ACKNOWLEDGES THAT THE PARTICULARS AND STATEMENTS SET FORTH HEREIN ARE MATERIAL TO THE ACCEPTANCE OF THE RISK ASSUMED BY THE INSURANCE COMPANY AND THAT THE INSURANCE COMPANY IS RELYING UPON THE TRUTH AND COMPLETENESS OF THE RISK FACTORS DISCLOSED HEREIN. IT IS AGREED BY THE UNDERSIGNED THAT THIS APPLICATION, INCLUDING ANY MATERIAL SUBMITTED HEREWITH, SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND THIS APPLICATION SHALL BE ATTACHED TO AND BECOME A PART OF THE POLICY. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE POLICY, THE MEMBER WILL NOTIFY THE UNDERWRITER IMMEDIATELY IN WRITING AND THE UNDERWRITER MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION OR PROPOSAL.
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