WARRANTY
(Applies to all parts of this application and attachments submitted)
It is hereby understood and agreed that if insurance is issued by virtue of completing this application and
any applicable supplemental applications, the Insurance is only issued on the reliance on the applicant’s
warranty of answers to the questions above and on any such supplemental applications. If, at the time a
certificate/policy is issued and ANY OF THE ABOVE WARRANTIES IS IN ANY RESPECT
INCORRECT, INCLUDING CLAIMS OR GROSS RECEIPTS, THE COVERAGE AFFORDED UNDER
THE CERTIFICATE/POLICY shall, without notice to the applicant, immediately and automatically cease,
& the certificate/policy shall BECOME NULL AND VOID. Warranties will survive a certificate/policy
if issued.
Please submit a diagram of your premises:
You can create one online here. (Will open in new window, just save your diagram and then attach it here).
Submit your Safety Rules:
Submit your Waiver:
SIGNATURE
Person Applying:
Title:
Date Submitted:
Terms of Agreement:
By checking this box, 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.
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.
Draw your signature
Please make sure that you have completed everything to the best of your knowledge before clicking the submit button.
Please make sure that you have completed everything to the best of your knowledge before going to the next page.