Application Form (Page 4 of 4) in pdf

If Applicant has an Employee Handbook, Employment Application, or Company Email/Internet Policy, a copy of each must be forwarded for

review by the Company.

As a condition of binding this insurance, the Applicant agrees:

1) to implement and distribute to each employee the Mandatory Written Policies identified above which are currently not in place as soon

as possible , but no later than 21 days after the inception date of this insurance. Failure of the Company to receive these policies within

21 days after the inception of this insurance will result in the cancellation of this insurance.

2) To adopt and distribute to each employee all changes required by the Company of the Applicant's Written Policies as soon as possible,

but no later than 21 days after receipt from the Company of the required changes.

Required Information Prior to Binding:

Copy of declarations page of Applicant's General Liability Policy.

List of all Managed Properties.

The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true. The undersigned further

declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate,

untrue, or incomplete any statement made will immediately be reported in writing to the Insurer and the Insurer may withdraw or modify

any outstanding quotations and/or authorization or agreement to bind the insurance. The Insurer is hereby authorized, but not required, to

make any investigation and inquiry in connection with the information, statements, and disclosures provided in this Application. The

decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and

shall not stop the Insurer from relying on any statement in this Application. The signing of this application does not bind the undersigned to

purchase the insurance, nor does the review of this Application in the event the Policy is issued. It is agreed that this Application shall be

the basis of the contract should a policy be issued and it will be attached and become a part of the policy.

ARIZONA, PENNSYLVANIA AND OREGON FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE

COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE

INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A

FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY BE SUBJECT TO A CIVIL PENALTY (AND A CRIMINAL PENALTY IF IN PENNSYLVANIA).

UTAH, CONNECTICUT AND OHIO FRAUD STATEMENT: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITAT-

ING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF

INSURANCE FRAUD.

VIRGINIA FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD AN INSURER, SUBMITS AN APPLICATION FOR

INSURANCE OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

FRAUD STATEMENT (ALL OTHER STATES):ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER

PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS

FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT,

WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE

CLAIM FOR SUCH VIOLATION.

Signature of the Applicant of the Insured: ____________________________________________________

Must be signed by a Principal, Partner or Officer of the Firm

Date: ___________________________

IF THE PRIMARY ADDRESS OF THE LOCATION LISTED IN ITEM #1 IS IN THE STATE OF NEW YORK, IOWA AND

FLORIDA, THE STATE OF NEW YORK, IOWA AND FLORIDA REQUIRE THAT WE HAVE THE NAMES AND ADDRESSES OF

YOUR (INSURED'S) AUTHORIZED AGENT OR BROKER.

NAME OF AUTHORIZED AGENT OR BROKER: _____________________________________________________________________

ADDRESS: ______________________________________________________________________________________________________

AGENT OR BROKER LICENSE NUMBER: __________________________________________________________________________

PM APP (12/19/2002)

Application Form Page 4