It is understood and agreed that with respect to questions 14 and 15, that if such knowledge or information exists any claim or action arising there from is excluded from this proposed coverage.
Notice to New York applicants: any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material thereto, commits a fraudulent insurance act, which is a crime.
The applicant hereby acknowledges that he/she/it is aware that the limit of liability shall be reduced, and may be completely exhausted, by the costs of legal defense and, in such event, the Insurer shall not be liable for the costs of legal defense or for the amount of any judgement or settlement to the extent that such exceeds the limit of liability.
The applicant further acknowledges that he/she/it is aware that legal defense costs that are incurred shall be applied against the deductible amount.
I DECLARE that, after inquiry, the above statements and particulars are true and I have not suppressed or misstated any material fact and that I agree that this application shall be the basis of the contract with the Underwriters.
This application form duly completed, together with any supplementary information, must be signed in ink or by electronic signature by the person indicated.
Signing of this form does not bind the applicant or the Underwriters to complete this insurance.
A copy of this application should be retained for your records.
You are not required to pay for services or utilize our office to secure insurance services in exchange for obtaining your insurance policy. While you have chosen to collaborate with Majdas Touch Insurance, Inc., you are under no obligation to do so, and you retain the freedom to explore other brokerages without incurring any fees. The decision to continue paying this fee is entirely voluntary, and you are making it of your own accord and volition.
