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QBPC 30 05 09 15 Page 1 of 1
1. Full name of applicant
2. It is understood and agreed that application is being made to the Company. All information contained in the application
dated (“Application”) and completed on behalf of the Applicant will be relied upon by the underwriting manager,
Company and/or affiliates thereof in issuing a policy.
3. The underwriting manager, Company and/or affiliates thereof will rely upon:
(a) The truth and accuracy of the representations contained in the Application;
(b) The applicant represents that the statements and any attachments to the Application are true and accurate to the
best knowledge and belief of the undersigned authorized agent of the person(s) and entity(ies) proposed for this
insurance and declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in
the Application and in any attachments, are true and complete;
Notice to the applicant – Please read carefully
No fact, circumstance or situation indicating the probability of a claim or action for which coverage may be afforded by the
proposed insurance is now known by any person(s) or entity(ies) proposed for this insurance other than that which is
disclosed in the Application. It is agreed by all concerned that if there be knowledge of any such fact, circumstance or
situation, any claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.
The policy applied for is solely as stated in the policy, if issued, which provides coverage on a claims made basis for only
those “claims” that are first made against the insured during the policy period, unless the extended reporting period
option is exercised in accordance with the terms of the policy. The policy has specific provisions detailing claim reporting
requirements.
The underwriting manager, Company and/or affiliates thereof are authorized to make any inquiry in connection with the
Application and this Statement.
I/We represent to the Company, that I/We understand and accept the notice stated above and that the information
contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company
evidence its acceptance of the Application and this Statement by issuance of a policy. I/We authorize the release of claim
information from any prior insurer to the underwriting manager, Company and/or affiliates thereof.
Signing this Statement does not bind the Company to provide or the applicant to purchase the insurance.
It is understood that information submitted herein becomes a part of the Application for insurance and is subject to the same
declarations, representations and conditions.
Must be signed by director, executive officer, partner or equivalent within 60 days of the proposed effective date.
Signing this Questionnaire does not bind the Company to provide or the applicant to purchase the insurance.
Application Acceptance and
Representation Statement (“Statement”)
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signature
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