Cossio Insurance Agency Party Equipment Rentals
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It is hereby understood and agreed that if insurance is issued by virtue of completing this application, the Insurance is only issued on the
reliance on the applicant’s warranty of answers to the questions above. 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.
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.
All values submitted are correct to the best of my knowledge & belief. Statement of Values submitted by:
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