The “Applicant” is the party to be named as the "Insured" in any insuring contract if issued. By signing this Application, the
Applicant for insurance hereby represents and warrants that the information provided in the Application, together with all
supplemental information and documents provided in conjunction with the Application, is true, correct, inclusive of all relevant
and material information necessary for the Insurer to accurately and completely assess the Application, and is not misleading
in any way. The Applicant further represents that the Applicant understands and agrees as follows: (i) the Insurer can and will
rely upon the Application and supplemental information provided by the Applicant, and any other relevant information, to
assess the Applicant’s request for insurance coverage and to quote and potentially bind, price, and provide coverage; (ii) the
Application and all supplemental information and documents provided in conjunction with the Application are warranties that
will become a part of any coverage contract that may be issued; (iii) the submission of an Application or the payment of any
premium does not obligate the Insurer to quote, bind, or provide insurance coverage; and (iv) in the event the Applicant has or
does provide any false, misleading, or incomplete information in conjunction with the Application, any coverage provided will
be deemed void from initial issuance.
The Applicant hereby authorizes the Insurer and its agents to gather any additional information the Insurer deems necessary
to process the Application for quoting, binding, pricing, and providing insurance coverage including, but not limited to,
gathering information from federal, state, and industry regulatory authorities, insurers, creditors, customers, financial
institutions, and credit rating agencies. The Insurer has no obligation to gather any information nor verify any information
received from the Applicant or any other person or entity. The Applicant expressly authorizes the release of information
regarding the Applicant’s losses, financial information, or any regulatory compliance issues to this Insurer in conjunction with
consideration of the Application.
The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a quote with a Sublimit
of liability for certain exposures, (ii) quote certain coverages with certain activities, events, services, or waivers excluded
from the quote, and (iii) offer several optional quotes for consideration by the Applicant for insurance coverage. In the event
coverage is offered, such coverage will not become effective until the Insurer’s accounting office receives the required
premium payment.
The Applicant agrees that the Insurer and any party from whom the Insurer may request information in conjunction with the
Application may treat the Applicant’s facsimile signature on the Application as an original signature for all purposes.
The Applicant acknowledges that under any insuring contract issued, the following provisions will apply:
1. A single Accident, or the accumulation of more than one Accident during the Policy Period, may cause the per Accident
Limit and/or the annual aggregate maximum Limit of Liability to be exhausted, at which time the Insured will have no further
benefits under the Policy.
2. The Insured may request the Insurer to reinstate the original Limit of Liability for the remainder of the Policy period for an
additional coverage charge, as may be calculated and offered by the Insurer. The Insurer is under no obligation to accept the
Insured's request.
3. The Applicant understands and agrees that the Insurer has no obligation to notify the Insured of the possibility that the
maximum Limit of Liability may be exhausted by any Accident or combination of Accidents that may occur during the Policy
Period. The Insured must determine if additional coverage should be purchased. The Insurer is expressly not obligated to
make a determination about additional coverage, nor advise the Insured concerning additional coverage.
4. The Insurer is herein released and relieved from any and all responsibility to notify the Insured of the possible reduction in
any applicable Limit of Liability. The Insured herein assumes the sole and individual responsibility to evaluate, consider, and
initiate a request for additional coverage or reinstatement of the annual aggregate Limit of Liability which may be exhausted by
any single Accident or combination of Accidents during the Policy Period.