O-2002-2546 - Laserfiche WebLink

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drawn in connection with this App~tion shall not constitute an acceptance ofllability. In the event that the C~atIY docs not approve this App1icatiOltt its sole obligation shaD. be to refUnd the deposit to the Applicant e) The App1ican.t represents that the statements and declarations made in this Application, the Disclosure Statement, and in the Plan n:ferred. to in this Application arc true and wmp1ete and that the Policy. when issued, WIll be issued in reliance upon the tnzth and completeness of such ~tanents and dec1ar.nions. The Disclosure Statemco.t, this Application and the Plan shall fann a part of the Policy. and the Policy shall embody all agreements existing between the Applicant and the Company, or any of their respective agents, relating to this Excess Loss Insurance for wbieh this Application is being made. 1) Any person who knowingly and with inte:nt to defraud ~ insurance company or other pasou files an application for insurance or statement of claim containing any materially false infonnation. or concc:a1s for the pwpose of misleading. information conccming any fact material thereto, commits a frauduk:nt insurance act, which is a crime, and shan also be subject to a civl1 penahynot to exceed five thousand doDars and the stated value oftbe claim for each such violation. The Applicant represents that it, directly or through its authorized agent. has read this Application in its entirety and bas been given the opportunity to ask my questions it may have. The Applicant further l.IDCbstands that the insurance requested docs not start unless this Application is approved and accepted by CFE Management LLC or the Company. Dated at: 3/ l~ Cay or TY\CLI{~ ;LooJ- Applicant (print ortypc name) C i t Y 0 f LaP 0 r t e ApplicantSignature: /f-4?1~.~_~-~ By: tJ 0 R m V1N L ~ mf>>lOYl/'6 Title; -_mOAf-t ( Q~ r: ~. C.t\I\. ; u-.dAgmt'sN_~): EJd;~e Licensed Agent's Slgn~: _ Dated at: ?/I~ /02- day of I ' SL-ZOOI-APP 4 (6/01) TOTAL P.la5