Please fully answer all questions and submit all requested information. Terms appearing in bold face in this Application are defined in the Policy and have the same meaning in this Application as in the Policy. If you do not have a copy of the Policy, please request it from your agent or broker. This Application, including all materials submitted herewith, shall be held in confidence.
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The undersigned Financial Advisor, on behalf of himself/herself and all of his/her employees, affiliates, and associates proposed to be insureds under the above-referenced insurance warrants to have no knowledge of any fact, circumstance, or situation that reasonably could result in a claim under the above-referenced insurance, except as disclosed in an attachment to this letter. If none, state so here:
none or attach here:
Without prejudice to any other rights of the Insurer, the undersigned acknowledges and understands that if such knowledge exists, then any claim arising from such fact, circumstance, or situation, whether or not disclosed, is excluded from coverage under the above-referenced insurance.
The undersigned further acknowledges and understands that if the Insurer issues a policy, it will be issued in reliance upon this warranty, which shall be deemed attached to and part of the application and policy.
I have read and accept these Terms.
Please read and accept the following terms:
THE POLICY FOR WHICH THIS APPLICATION IS SUBMITTED IS WRITTEN ON A CLAIMS MADE AND REPORTED BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD IF APPLICABLE, AND REPORTED IN WRITING TO THE INSURER PURSUANT TO THE TERMS THEREIN. THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS MAY BE REDUCED AND MAY BE TOTALLY EXHAUSTED BY AMOUNTS INCURRED AS DEFENSE COSTS. ANY DEDUCTIBLE MAY BE SIMILARLY REDUCED OR EXHAUSTED BY AMOUNTS INCURRED AS DEFENSE COSTS. PLEASE READ THE POLICY CAREFULLY.
The undersigned Applicant declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this statement changes between the date of this statement and the effective date of the insurance, they shall, in order for the information to be accurate on the effective date of the insurance, immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or authorizations or agreements to bind the insurance.
Signing of this Application does not bind the Applicant or the Insurer to complete the insurance contract, but it is agreed that this statement shall be the basis of the contract should a policy be issued, and it will be attached to and become part of the Policy.
All written statements and materials furnished to the Insurer in conjunction with this Application are hereby incorporated by reference into this Application and made a part hereof.
I agree to receive occasional emails from Axis Insurance Managers Inc. I may withdraw my consent at anytime.
MINIMUM RETAINED PREMIUM: IN THE EVENT OF A CANCELLATION, A MINIMUM RETAINED PREMIUM OF $250 SHALL APPLY. ADMINISTRATION FEES AND TAXES ARE FULLY EARNED AND NON REFUNDABLE. Please contact us if you want to cancel your policy.
I agree