Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I / We declare that if the firm or any of its members become aware of any information that would change answers furnished in the application, the firm will reveal such information in writing to the Company prior to the effective date of coverage.
On behalf of the applicant firm, I declare that this application, including attachments, supplementary pages and other exhibits attached, is complete and correct to the best of my knowledge and belief. I understand that the application shall form the basis of the contract of insurance should the Company offer coverage and should the firm accept the Company’s quotation. I also understand that completion of this application does not bind the Company or broker to provide insurance.