Confirmation
  1. NOTE: Remember not to hit your back button or your refresh button so that you do not
    accidentally erase or wipe out any type of information that you have typed in.
  2. 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.
  3. 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.
  4. All values submitted are correct to the best of my knowledge & belief. Statement of Values submitted by:
Please make sure that you have completed everything to the best of your knowledge before going to the next page.