Fillable LICATION ACCEPTANCE AND REPRESENTATION STATEMENT (Statement) APP 2. (Risk Placement Services, Inc.)

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LICATION ACCEPTANCE AND REPRESENTATION STATEMENT (Statement) APP 2. (Risk Placement Services, Inc.)

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MALP 0023 07 13 Page 1 of 2
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
APP
LICATION ACCEPTANCE AND REPRESENTATION STATEMENT (“Statement”)
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.
REPRESENTATION
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.
NOTICE: By applying for this insurance, the applicant also is applying for membership in Premier Attorneys Purchasing
Group, Inc., a purchasing group formed and operating pursuant to the Federal Liability Risk Retention Act of 1986 (15 USC
3901 et seq.). This purchasing group was formed for the sole purpose of providing professional errors and omissions
liability insurance to lawyers. The sole purpose of becoming a member is to purchase professional liability insurance.
Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the
third degree.
Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
MALP 0023 07 13 Page 2 of 2
Must be signed by director, executive officer, partner or equivalent within 60 days of the proposed effective date.
Name of Applicant Title
Signature of Applicant Date
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
Notice to Alabama Applicants; Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution, fines, or confinement in prison, or any combination thereof.
Notice to Arkansas, District Of Columbia, New Mexico, Rhode Island And West Virginia Applicants: Any person who
knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in
an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall
be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Notice to Kansas Applicants: It is unlawful to commit a “fraudulent insurance act” which means an act committed by any
person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief
that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of,
or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial
insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance
which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the
purpose of misleading, any information concerning any fact material thereto.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Notice to Maine, Tennessee, Virginia and Washington Applicants: It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties may include
imprisonment, fines, or denial of insurance benefits.
Notice to Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
Notice to Ohio Applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Notice to Oklahoma Applicants: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may be
guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other states: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime and subjects the person to criminal and civil penalties.
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LICATION ACCEPTANCE AND REPRESENTATION STATEMENT (Statement) APP 2. (Risk Placement Services, Inc.)

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Completed 23 November 2020

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