Description of Loan & Exposure

Coverage Requested

Read and Sign Below

I hereby state that the information contained herein is true, accurate and complete and no material facts have been omitted, misrepresented or misstated. I understand that any willful misrepresentations or material inaccuracies in this Application will void any coverage under any policy of insurance issued because of the submission of this Application. I have read Schedule 1 of this Application and acknowledge that I have been given the opportunity to request clarifying questions and understand the requirements therein. I understand that this is an application for insurance coverage only and that completion and submission of this Application does not guarantee or bind coverage with any insurer. I also represent that I am an authorized representative of the Applicant and attest that the Applicant is an Industrial Insured or Large Commercial Risk entity and satisfies the definition of Industrial Insured or Large Commercial Risk of the Applicant’s domiciled or home state laws. I further understand the Applicant is applying for coverage from an insurance carrier that the policy the Applicant receives, if this Application is accepted, may contain rates and forms that have not been reviewed by applicable departments of insurance due to Large Commercial Risk and/or Industrial Insured state exemptions.

Required Attachments