NOTICE - PLEASE READ CAREFULLY
NO FACT, CIRCUMSTANCE, OR SITUATION INDICATING THE PROBABILITY OF A CLAIM OR ACTION FOR WHICH COVERAGE MAY BE AFFORDED BY THE
PROPOSED INSURANCE IS NOW KNOWN BY ANY PERSON(S) OR ORGANIZATION(S) PROPOSED FOR THIS INSURANCE OTHER THAN THAT WHICH
IS DISCLOSED IN THIS APPLICATION. IT IS AGREED BY ALL CONCERNED THAT IF THERE IS KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE, OR
SITUATION, ANY CLAIM SUBSEQUENTLY EMANATING THEREFROM WILL BE EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED AUTHORIZED AGENT OF THE PERSON(S) AND ORGANIZATION(S) PROPOSED FOR
THIS INSURANCE DECLARES THAT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS IN THIS
APPLICATION AND IN ANY ATTACHMENTS, ARE TRUE AND COMPLETE. THE INSURER AND AFFILIATES THEREOF ARE AUTHORIZED TO MAKE ANY
INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS APPLICATION DOES NOT BIND THE INSURER TO PROVIDE OR THE ORGANIZATION
TO PURCHASE THE INSURANCE.
THIS APPLICATION, INFORMATION SUBMITTED WITH THIS APPLICATION, AND ALL PREVIOUS APPLICATIONS AND MATERIAL CHANGES THERETO
ARE CONSIDERED PHYSICALLY ATTACHED TO AND PART OF THE POLICY IF ISSUED. THE INSURER HAVE RELIED UPON THIS APPLICATION AND ALL
SUCH ATTACHMENTS IN ISSUING THE POLICY.
IF THE INFORMATION IN THIS APPLICATION AND ANY ATTACHMENT MATERIALLY CHANGES BETWEEN THE DATE THIS APPLICATION IS SIGNED AND
THE EFFECTIVE DATE OF THE POLICY, THE ORGANIZATION WILL PROMPTLY NOTIFY THE INSURER OR ITS AUTHORIZED REPRESENTATIVE, WHO MAY
MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION OR AGREEMENT TO BIND COVERAGE.
THE UNDERSIGNED DECLARES THAT THE PERSON(S) AND ORGANIZATION(S) PROPOSED FOR THIS INSURANCE UNDERSTAND THAT:
THE POLICY FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD.
REPRESENTATION
The undersigned represents to the Insurer that the person(s) and organization(s) proposed for this insurance understand and accept the notice stated
above and further represents that the information contained herein is true and will be the basis of the policy and deemed incorporated therein, should
the Insurer evidence its acceptance of this application by issuance of a policy.
The undersigned authorizes the release of claim information from any prior insurer to the Insurer.
This application is signed by undersigned authorized agent of the organization(s) on behalf of the organization(s) and its, directors, officers, and
employees.
I understand that Matterhorn Protects Insurance Group, Inc., for the insuring company, shall be permitted but not obligated to inspect a proposed
insured’s, or an insured’s, property and operations for underwriting purposes at any time. Neither the right to make an underwriting
inspection nor the making thereof nor any report thereon shall constitute an undertaking, on behalf of or for the benefit of any insured,
or other, to determine or warrant that such property or operations are safe or healthful, or in compliance with any standards, rules or
regulations. Underwriting inspections when conducted are for the sole purpose of determining and/or improving the insurability of certain
property and operations and not safety. I also understand that an insured is solely responsible for the safety of its facilities and operations
and shall not rely upon any underwriting inspections to determine the safety of its facilities or operations and shall not diminish or forego
its own safety practices and procedures.
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information
contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my
knowledge, all information provided is complete, true and correct.
I also understand that no insurance will be in effect unless and until the insurance company, or Matterhorn Protects as its agent, provides a quotation
offering to provide insurance coverage and the insurance company, or Matterhorn Protects as its agent, receives written notice that the terms and
conditions contained in the insurance quotation provided are accepted.
I agree that my electronic signature is the legally binding equivalent to my handwritten signature. I will not, at any time in the
future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.