USE THE FOLLOWING CATEGORY BREAKDOWNS TO HELP YOU DETERMINE YOUR “PROPERTY VALUES” BELOW
PLEASE ATTACH A SUPPLEMENTARY PAGE OUTLINING ALL OF YOUR STERILIZATION PROCEDURES AS WELL AS POLICIES IN PLACE TO PREVENT CROSS-CONTAMINATION
PLEASE ATTACH A SUPPLEMENT PAGE OUTLINING ALL OF YOUR STERILIZATION PROCEDURES AS WELL AS POLICIES IN PLACE TO PREVENT CROSS-CONTAMINATION
Any person who knowingly and with intent to defraud any insurance company or another person, files and application containing any false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects this person to criminal and civil penalties.
Our brokerage and the insurance industry have a solid track record of respecting your right to privacy and safeguarding your personal information. As a result of federal legislation, we’ve further strengthened our privacy commitment by informing you of why and how we collect, use and disclose your personal information. You can be assured that we’ll only handle your personal information in a manner that a reasonable person would consider appropriate in the circumstances.
The applicant agrees to notify the company of any material changes in the answers to the questions on this questionnaire which may arise during the course of this policy issued and further understands that claims may be denied if information regarding these material changes was not provided. The purpose of this questionnaire is to assist in the underwriting process. Information contained herein is specifically relied on in determination of insurability.
The under-signed, therefore, warrants that the information contained herein is true and accurate to the best of his / her knowledge, information, and belief. The questionnaire and the application shall be the basis of any insurance policy that be issued and will be part of such policy.
A consumer report containing personal, credit, factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal, extension or variation thereof. Signing of this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk, but it is agreed that this form shall be the basis of the contract should a policy be issued.
The Client hereby acknowledges that by completing and returning the application to Acumen Insurance Group Inc., you agreed to and consent to the collection, use and disclosure of such information, including any personal information, by AcumenInsurance Group Inc. for the following purposes: