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If Yes, please provide full particulars (Name, Description of Service, and Gross Income)
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If yes, please provide the following
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Please attach copies of following documents:
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Warranty

The Undersigned declare that to the best of their knowledge the statements set forth herein and any documents and information submitted in connection herewith are true, accurate and complete and that every effort has been made to obtain sufficient information from each and every person proposed for this coverage to facilitate the proper and accurate completion of this Application Form. The undersigned further declare that they have not suppressed, omitted, or misstated any material facts. The undersigned agree that if the information supplied on or in connection with this Application Form changes between the date of this Application Form and the effective date of the coverage, the undersigned will immediately notify Brokers’ Risk Placement Service, Inc. and Brokers’ Risk Placement Service, Inc., in its sole discretion, may withdraw or modify any outstanding quotations or authorization or agreement to bind coverage. The signing of this Application Form does not bind the applicant to purchase the coverage. However, it is agreed that this Application Form and any documents or information submitted herewith shall be the basis of the contract should a Coverage Agreement be issue and are to be considered as incorporated in and constituting part of the Coverage Agreement.

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This application must be signed and dated by an Officer of the Association, and not earlier than 60 days before the proposed effective date.

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By typing your name in this box and clicking submit you are accepting the terms of this Application Form. (Must be signed by an Officer of the Association)
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All data on this application is considered highly confidential and is only for Company's use. Signing this Application Form does not bind the Company to provide this Insurance, but it is agreed that this Application Form shall be made a part of this certificate and shall be the basis of the contract should the certificate be issued.
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