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*NOTE: Locations with 21+ units in a building are not permitted at this time for general liability.
There are no known losses or claims that have not already been reported to a prior insurance carrier, or to any other source from which claims might be made; There is no knowledge of facts or circumstances that relate to an occurrence, wrongful act, or incident of any type, including those caused by incremental, continuous, or progressive damage; arising from any of the insured’s operations, employees, or affiliates acting on the insured’s behalf which could reasonably result in a claim, that have not been reported to a prior insurance carrier; There is no knowledge of any requests for information by anyone, including an attorney, which might result in a claim; and There is no knowledge of any prior insurance carrier refusing coverage for, or declining to accept a report of any occurrence, incident, threat of claim, letter of intent, adverse result notice, or attorney contact.
By initialing here, you are hereby agree to the following State Specific Guidelines.
By initialing here, you are hereby agree to the following RPG Agreement.
An example policy for your reference can be found here.
THE UNDERSIGNED EXECUTIVE OFFICER, DIRECTOR, PARTNER, OR EQUIVALENT insured OR AUTHORIZED REPRESENTATIVE DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AGREES THAT IF THE INFORMATION SUPPLIED ON THE APPLICATION CHANGES BETWEEN THE DATE OF THE APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE. SIGNING OF THIS APPLICATION DOES NOT BIND THE insured TO THE INSURER TO COMPLETE THE INSURANCE.
THE insured AGREES TO NOTIFY US OF ANY MATERIAL CHANGES IN THE ANSWERS TO THE QUESTIONS ON THIS QUESTIONNAIRE WHICH MAY ARISE PRIOR TO THE EFFECTIVE DATE OF ANY POLICY ISSUED PURSUANT TO THIS QUESTIONNAIRE AND THE insured UNDERSTANDS THAT ANY OUTSTANDING QUOTATIONS MAY BE MODIFIED OR WITHDRAWN BASED UPON SUCH CHANGES AT OUR SOLE DISCRETION. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. insured's ACCEPTANCE OF THE COMPANY'S QUOTATIONS IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART OF THIS APPLICATION.