Please answer all the questions on this form. Before any question is answered please carefully read the
declaration at the end of the application form, which you are required to sign. Underwriters will rely on the statements that you make on this form. In this context, ANY INSURANCE COVERAGE THAT MAY BE ISSUED
BASED UPON THIS FORM WILL BE VOID IF THE FORM CONTAINS FALSEHOODS, MISREPRESENTATIONS, OR OMISSIONS. PLEASE TAKE CARE IN FILLING OUT THIS FORM.
You may provide any further additional information by means of a separate attachment if necessary.
By accepting this insurance you consent to Ascent Underwriting using the information we may hold
about you for the purpose of providing insurance and handling claims, if any, and to process
sensitive personal data about you where this is necessary (for example health information or criminal convictions).
This may mean we have to give some details to third parties involved in providing insurance cover.
These may include insurance carriers, third party claims adjusters, fraud detection and prevention services,
reinsurance companies and insurance regulatory authorities.
Where such sensitive personal information relates to anyone other than you, you must obtain the explicit
consent of the person to whom the information relates both to the disclosure of such information to us
and its use by us as set out above. The information provided will be treated in confidence and in compliance
with relevant Data Protection legislation. You have the right to apply for a copy of your
information (for which we may charge a small fee) and to have any inaccuracies corrected.
By accepting this insurance you confirm that the facts contained in the proposal form are true.
These statements, and all information you or anyone on your behalf provided before we agree to insure you,
are incorporated into and form the basis of your policy. If anything in these statements is not correct,
we will be entitled to treat this insurance as if it had never existed. You should keep this Statement of Fact
and a copy of the completed proposal form for your records.
This application must be signed by the applicant. Signing this form does not bind the company to complete the
insurance. With reference to risks being applied for in the United States, please note that in certain states,
any person who knowingly and with intent to defraud any insurance company or other person submits an application
for insurance containing any false information, or conceals the purpose of misleading information concerning any
fact material thereto, commits a fraudulent insurance act, which is a crime.
The undersigned is an authorized principal, partner, director, risk manager, or employee of the applicant and
certifies that reasonable inquiry has been made to obtain the answers herein which are true, correct and
complete to the best of his/her knowledge and belief. Such reasonable inquiry includes all necessary inquiries
to fellow principals, partners, directors, risk managers, or employees to enable you to answer the questions
(Use your mouse to draw the signature inside the box below)
Send to Dee@interwebinsurance.com Questions: Call Dee at (804) 761-6608