I may have provided personal information in this document and by other means 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 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, renewals, changes of coverage, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.
I declare that to the best of my knowledge, all the information on this questionnaire is true and that these statements are the declarations upon which insurance coverage is provided. Signing this form does not bind the applicant or the Insurer to complete the Insurance.