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Section 11: Submission Requirements
In order to process your application we need you to attach the following documents:
Completed Application with all Questions Answered
Currently valued insurance company loss runs for the current policy period plus 5 prior years
Resume (New Business Only)
Business Plan (New Business Only)
Diagram of premises
Daily Safety Checklist
Section 11b: WARRANTY AND DISCLOSURE
I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form 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. Cossio Insurance Agency as managing general underwriter for the insurance company, receives compensation from the insurance company in consideration for its performance of insurance services that include, but are not limited to; underwriting, policy/certificate issuance, administration and claims handling. The insurance company compensates Cossio Insurance, based on a predetermined calculation of thirty-three percent of the total premium. I understand that, subject to applicable laws, Cossio Insurance Agency will invest the premium and, in accordance with the permission of the insurer, will receive any interest or other income that the premium generates prior to remittance to the insurer. I am aware that the insurance company expects accurate reporting for my premium calculation. I understand that my books and records may be examined or audited by the insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may jeopardize coverage. I further acknowledge that, I have reviewed all information provided with this enrollment form and understand the exclusions which apply, as well as the activities and operations for which coverage is not provided.
Terms of Agreement:
By signing below, I hereby agree to the terms of filling out this application, and I also announce that I have filled this application out with the best of my knowledge.
Print your name
Draw your signature
I accept the terms of this agreement.