I/We hereby declare that:
My/Our attention has been drawn to the Important Notice accompanying this Application form and further I/we have read these notices carefully and acknowledge my/our understanding of their content by my/our signature/s below.
The above statements are true, and I/we have not suppressed or mis-state any facts and should any information given by me/us alter between the date of this Application form and the inception date of the insurance to which this Application relates I/we shall give immediately notice thereof.
I/We authorize Nsure General Insurance Advisors to collect or disclose any personal information relating to this insurance to/fom any other insurances or insurance reference service. Where I/we have provided information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact.
I/We also confirm that the undersigned is/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Application form and I/we complete this Application form on their behalf.
To be signed by the Chairman/President/Managing Partner/Managing Director/Principal of the association/partnership/ company/practice/business.