7. Hull Insurance (Schedule separately and note any limitations on collision and/or tower’s liability)
D. Terrorism Coverage – Indicate which underlying insurances contain TRIA coverage and/or any other Terrorism coverage
10. DETAILS OF LIABILITY LOSSES, INSURED OR UNINSURED, SETTLED OR PENDING EXCEEDING $25,000 IN LAST FIVE YEARS:
11. DETAILS OF ANY SPECIFIC LIMITATIONS OR EXCLUSIONS IN PRIMARY INSURANCE NOT OTHERWISE NOTED:
12. DESCRIBE ANY KNOWN DEFICIENCIES OF INSURED OR ANY OTHER RELEVANT FACTS WHICH MIGHT AFFECT UNDERWRITER’S
JUDGEMENT WHEN CONSIDERING THIS APPLICATION:
13. LIMITS DESIRED:
You understand and agree this application is a request for a quote based on the information provided herein. You understand and agree the actual coverage, terms and conditions offered
by RPS may be different than your request contained herein. The actual terms and conditions for coverage provided are represented by the policies issued and supersede any request or
representations made prior to issuance.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.
The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated.
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Signature:
Date:
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