Specialty Training School Product

Transcription

1 USLI.COM Specialty Training School Prodct As a school owner, do yo have the right coverage? General liability that incldes coverage for mental angish or emotional distress Coverage for professional acts is inclded for most schools Coverage for abse or molestation on many classes Why yo shold choose the United States Liability Insrance Grop s Specialty Training School: Coverage Featres Or Grop Competitors Policy General liability that expands the definition of bodily injry to inclde mental angish or emotional distress No liability dedctible Professional Liability coverage inclded on most classes Replacement cost available Special case of loss available Eqipment breakdown coverage available Vale pls endorsement is available on acconts eligible for special form offering 15 valable coverage enhancements; inclding water back-p, money and secrities, employee dishonesty, signs, transit and more No classification limitation endorsement No designated premises endorsement Why choose to be insred with United States Liability Insrance Grop? One of only 20 A++ rated insrance grops in the United States by A.M. Best. A prod member of the Berkshire Hathaway Grop, recently voted the #1 most admired property and casalty company in the world (Fortne Magazine). Insre yor financial well-being with a stable Company that will be there to pay yor claim. This docment does not amend, extend or alter the coverage afforded by the policy. For a complete nderstanding of any insrance yo prchase, yo mst first read yor policy, declaration page and any endorsements and discss them with yor broker. A specimen policy is available from an agent of the company. Yor actal policy conditions may be amended by endorsement or affected by state laws. STSP-POS-6-11

2 USLI.COM Specialty Training School Prodct We offer a comprehensive insrance prodct for the following types of specialty schools: Art instrction Athletic instrction Bartending school Beaty schools Bsiness/secretarial/paralegal Charm/modeling schools Compter training Cooking instrction Craft/hobby Dance schools Dressmaking classes Drama/theater training Insrance training Langage instrction Massage school Medical/nrsing classroom instrction Msic training Personal Trainer Photography classes Poker/gambling school Pblic speaking Reading instrction Real estate training SAT/LSAT corses Ttoring services Wine tasting school Prodct Featres: No liability dedctible No designated premises endorsement Special form available Replacement cost available Additional Advantages: A.M. Best rated A++ carrier Qick qote trnarond Sperior policy issance Low minimm premim Coverages available: General Liability Professional liability inclded on most classes for no charge Abse or molestation sb limit available on many classes Property Eqipment breakdown This docment does not amend, extend or alter the coverage afforded by the policy. For a complete nderstanding of any insrance yo prchase, yo mst first read yor policy, declaration page and any endorsements and discss them with yor broker. A specimen policy is available from an agent of the company. Yor actal policy conditions may be amended by endorsement or affected by state laws. STSPP-NR -6/11

3 USLI.COM Specialty Training School Prodct Claim Examples General liability: A stdent of the pblic speaking school slipped and fell in the school s restroom. The reslting injries were a broken arm and sprained knee. The stdent filed a lawsit against the school for pain and sffering, medical bills and rehabilitation expenses. The lawsit was settled in the amont of $68,000 and $7,000 were paid in defense expenses. Professional: A mother claimed that the learning center failed to render professional services in ttoring her child for the SAT s he is now nable to get into the college he wanted to attend. The parents broght a lawsit against the school for the cost to hire a special ttor and a refnd of their money paid to the learning center. The claim was settled in the amont of $10,000. Property: A fire began at the insred s premises when an employee of the compter instrction school plgged in the compters. The fire cased $80,000 in bilding damage along with $36,000 in damages to bsiness personal property. While the damages were being repaired, the compter instrction school had to sht down for two months. This reslted in a bsiness income loss of $15,000 along with $10,000 in extra expenses to get the school p and rnning again. The entire loss came to $141,000 in damages and the claim was settled for the insred s damages. Eqipment breakdown: A cast iron boiler experienced a low water condition and was destroyed casing $18,400 in property damage. Abse or molestation: A stdent attending a dance school broght a lawsit against the school alleging negligent hiring of an instrctor who improperly toched her dring a lesson. Attorneys were hired to defend the school. The case was dismissed after no negligence was fond on the part of the school. Defense costs were paid in the amont of $35,000. This docment does not amend, extend or alter the coverage afforded by the policy. For a complete nderstanding of any insrance yo prchase, yo mst first read yor policy, declaration page and any endorsements and discss them with yor broker. A specimen policy is available from an agent of the company. Yor actal policy conditions may be amended by endorsement or affected by state laws. STSP-CLA-6/11

4 USLI.COM Specialty Training School Application - All States YOU CAN OBTAIN AN INSTANT QUOTE BY PROVIDING THE INFORMATION IN SECTION I - INSTANT QUOTE INFORMATION, SUBJECT TO THE REMAINDER OF THE APPLICATION COMPLETED PRIOR TO BINDING. I. INSTANT QUOTE INFORMATION Instant Qote is only available for acconts with no losses in the past three years. If there is loss history, please complete the entire application. Applicant s name: Location address: Same as mailing address City: State: Zip code: address of primary contact: Description of operations: Classification (Type of school): Art instrction Athletic instrction Bartending Beatician Bsiness Charm/Modeling Compter Cooking Craft/Hobby Dance Drama/Theater Dressmaking Hobby Insrance Langage Massage Medical/Nrsing Msic Paralegal Personal trainer Photography Poker/Gambling Pblic speaking Reading Real estate Training agents only Secretarial/Administrative assistant. Tailor In-home ttors Ttoring centers Wine tasting What year did the bsiness start? How many years has the applicant been at the crrent location? Do yo own the bilding? (If no, skip bilding owner qestions nder both the Property & Liability Sections below) Yes No Property Section Bilding constrction (please check one): Frame - Bilding is made from a wood frame (2x4s/veneers) Joisted masonry - Otside walls are constrcted with bricks/cinder blocks. Roof is made of wood Masonry non-combstible - Same as joisted masonry, except roof is steel Fire resistive - Strctral steel framing, reinforced concrete otside/load bearing walls Other Protection class: Reqested case of loss: Basic Special Reqested valation: Replacement cost Actal cash vale Dedctible: $1,000 $2,500 $5,000 Coinsrance: 80% 90% 100% Bsiness personal property limit $ Bsiness income and extra expense limit $ STSA 8/12 page 1 of 5

5 Bilding Owner: Bilding limit $ What year was the bilding constrcted? What is the sqare footage of the entire strctre? sq. ft. What is the sqare footage of portion occpied by applicant? sq. ft. Liability Section General liability limit: $100,000/$200,000 $300,000/$600,000 $500,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/$3,000,000 Abse or molestation liability limit: $25,000/$50,000 $50,000/$100,000 $100,000/$100,000 (This coverage is not available on $100,000/$300,000 $300,000/$300,000 the following classes: Athletic instrction, Charm/Modeling, Drama/Theater, Massage, Msic, Personal trainers and In-home ttors) Annal sales: Total nmber of teachers: Annal nmber of stdents: Does the school operate: All year or details Any off premises events? Yes No If Yes, provide details: No school with any overnight events or activities Tre False Permission slips obtained from parents/gardian for all field trips N/A Tre False No field trips to off premise swimming pools, lakes, beaches, skiing, ice/roller skating rinks N/A Tre False or amsement/water parks No pblic or private elementary, jnior or senior high school Tre False No school that focses on learning disabled, physically or mentally challenged children Tre False Bilding Owner: Is any portion of the bilding leased to commercial tenants? Yes No If Yes, applicable sq. ft. Does the applicant lease any apartments at this location? Yes No If Yes, Nmber of Units Applicable sq. ft. of Apts. Additional Interests (AI = Additional Insred, LP = Loss Payee, M = Mortgagee) Name Relationship/Interest Address City, State, Zip AI LP M II. LOSS INFORMATION FOR THE PAST THREE YEARS Property coverages None, or provide details below. Year Stats Incrred Description Open/Closed $ Open/Closed $ Open/Closed $ Liability coverages None, or provide details below. Year Stats Incrred Description Open/Closed $ Open/Closed $ Open/Closed $ III. ADDITIONAL PROPERTY INFORMATION 1.If yo own the bilding and it is more than 10 years old, please complete the following: Age of roof (yr): Plmbing pdated (yr): Electrical pdated (yr): Heating pdated (yr): Roof type: Flat Wood shake Shingle Metal Tile Slate Other: Plmbing type: PVC Copper Lead Galvanized Other: What type of brglar alarm is on the premises? Central station Local None STSA 8/12 page 2 of 5

6 IV. ELIGIBILITY CRITERIA 1. No bankrptcies, tax or credit liens against the applicant in the last five years Tre False 2. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missori) Tre False If False, advise reason 3. Insred does not occpy more than 25,000 sqare feet of the premises Tre False 4. No armed secrity on premises at any time Tre False 5. For any bilding bilt prior to 1978, 100% of the electric wiring is on fnctioning and operating circit breakers N/A Tre False 6. For any bilding bilt prior to 1978, there is no alminm wiring or knob and tbe wiring N/A Tre False 7. Fnctioning and operating smoke and/or heat detectors in all nits and/or occpancies Tre False General Liability 1. Backgrond and criminal checks completed on all staff and volnteers Tre False 2. No more than $3,000,000 in annal sales Tre False 3. No swimming pools Tre False 4. No on-water activity or instrction Tre False 5. No archery, firearms or other weapons activities or training Tre False 6. No cheerleading or gymnastic activities, eqipment or instrction Tre False 7. No karate, martial arts or similar type activity or instrction Tre False 8. No physical therapy or rehabilitation services offered Tre False 9. The applicant has not, is not and will not act as a franchisor (grantor of a franchise) Tre False Art & Craft/Hobby Instrction 1. Kilns are UL approved Tre False 2. Proper storage of all paints and flammables in metal file cabinets Tre False 3. No glassblowing operations Tre False Athletic Instrction, Dance Instrction and Personal Trainers 1. All participants/gardians mst sign a waiver of liability/release of liability as a condition of participation Tre False 2. No professional athlete training Tre False Cooking 1. Commercial cooking protected by extingishing system meeting NFPA #96 standards Tre False 2. Annally serviced fire extingishers monted by cooking eqipment Tre False Medical/Nrsing 1. No lab or clinical training; contemplates classroom training only Tre False 2. No CPR or first aid schools or instrctors Tre False 3. No childbirth or parenting classes Tre False V. ADDITIONAL APPLICANT INFORMATION Form of bsiness: Individal Corporation Partnership LLC Other: Applicant s mailing address: (if different than the location address above) City: State: Zip code: address of primary contact: Phone: Inspection contact name: Telephone/ address: FRAUD STATEMENTS Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery nder the policy only if the misrepresentations, omissions, concealment of facts or incorrect statements are; fradlent or material either to the acceptance of the risk, or to the hazard assmed by the insrer or the insrer in good faith wold either not have issed the policy, or wold not have issed a policy in as large an amont, or wold not have provided coverage with respect to the hazard reslting in the loss, if the tre facts had been made known to the insrer as reqired either by the application for the policy or otherwise. Colorado Frad Statement: It is nlawfl to knowingly provide false, incomplete, or misleading facts or information to an insrance company for the prpose of defrading or attempting to defrad the company. Penalties may inclde imprisonment, fines, denial of insrance and civil damages. Any insrance company or agent of an insrance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the prpose of defrading or attempting to defrad the policyholder or claimant with regard to a settlement or award payable from insrance proceeds shall be reported to the Colorado division of insrance within the department of reglatory agencies. District of Colmbia Frad Statement: WARNING: It is a crime to provide false or misleading information to an insrer for the prpose of defrading the insrer or any other person. Penalties inclde imprisonment and/or fines. In addition, an insrer may deny insrance benefits if false information materially related to a claim was provided by the applicant. Florida Frad Statement: Any person who knowingly and with intent to injre, defrad, or deceive any insrer files a statement of claim or an application containing any false, incomplete, or misleading information is gilty of a felony of the third degree. FLORIDA NOTICE FOR NON ADMITTED POLICIES ONLY: Yo are agreeing to place coverage in the srpls lines market. Sperior coverage may be available in the admitted market and at a lesser cost. Persons insred by srpls lines carriers are not protected nder the Florida Insrance Garanty Act with respect to any right of recovery for the obligation of an insolvent nlicensed insrer. STSA 8/12 page 3 of 5

7 Florida and Illinois Notice: I nderstand that there is no coverage for pnitive damages assessed directly against an insred nder Florida and Illinois law. However, I also nderstand that pnitive damages that are not assessed directly against an insred, also known as vicariosly assessed pnitive damages, are insrable nder Florida and Illinois law. Therefore, if any Policy is issed to the Applicant as a reslt of this Application and sch Policy provides coverage for pnitive damages, I nderstand and acknowledge that the coverage for Claims broght in the State of Florida and Illinois is limited to vicariosly assessed pnitive damages and that there is no coverage for directly assessed pnitive damages. Kansas Frad Statement: Any person who, knowingly and with intent to defrad, presents, cases to be presented or prepares with knowledge or belief that it will be presented to or by an insrer, prported insrer, broker or any agent thereof, any written statement as part of, or in spport of, an application for the issance of, or the rating of an insrance policy for personal or commercial insrance, or a claim for payment or other benefit prsant to an insrance policy for commercial or personal insrance which sch person knows to contain materially false information concerning any fact material thereto; or conceals, for the prpose of misleading, information concerning any fact material thereto may be gilty of a crime and may be sbject to fines and confinement in prison. Kentcky Frad Statement: Any person who knowingly and with intent to defrad any insrance company or other person files an application for insrance containing any materially false information or conceals, for the prpose of misleading, information concerning any fact material thereto commits a fradlent insrance act, which is a crime. Maine and Washington Frad Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insrance company for the prpose of defrading the company. Penalties may inclde imprisonment, fines or a denial of insrance benefits. Maryland: Any person who knowingly or willflly presents a false or fradlent claim for payment of a loss or benefit or who knowingly or willflly presents false information in an application for insrance is gilty of a crime and may be sbject to fines and confinement in prison. Athorization or agreement to bind the insrance may be withdrawn or modified only based on changes to the information contained in this application prior to the effective date of the insrance applied for that may render inaccrate, ntre or incomplete any statement made with a minimm of 10 days notice given to the insred prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premim. MISSOURI SPECIAL NOTICE - FOR REAL ESTATE PRODUCTS SOLD IN MISSOURI Missori Disclosre Notice: I nderstand and acknowledge that as respects Discrimination and Lock Box coverage that Claims Expenses are a part of the Limit of Liability. This means that Claims Expenses will redce my limits of insrance and may exhast them completely and shold that occr; I shall be liable for any frther Claims Expenses. Claims Expenses are as defined in Section VII. I also nderstand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations. MISSOURI SPECIAL NOTICE - FOR SUPERTEK AND MICROTEK PRODUCTS SOLD IN MISSOURI Missori Disclosre Notice: I nderstand and acknowledge that Claims Expense or defense costs are a part of the limits of insrance for the MicroTek prodct. I also nderstand and acknowledge that Claims Expenses are part of the limits of insrance for Intellectal Property Claims coverage, if chosen, nder the Technology prodct. Any defense costs paid nder this coverage part will redce the available limits of insrance and may exhast them completely. Defense costs means reasonable and necessary fees, costs and expenses reslting solely from the investigation, legal defense and legal appeal of a claim against the Insred, bt exclding salaries of officers and employees of the Insrer. MISSOURI SPECIAL NOTICE - FOR EPL, CORPORATE D&O AND NON PROFIT D&O PRODUCTS SOLD IN MISSOURI Missori Disclosre Notice: I nderstand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if the Insred Organization has more than 200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs will redce my limits of insrance and may exhast them completely and shold that occr, I shall be liable for any frther legal Defense Costs and Damages. Defense Costs are as defined in Section III. I also nderstand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations. MISSOURI SPECIAL NOTICE - FOR COMMUNITY ASSOCIATIONS PRODUCT SOLD IN MISSOU ri Missori Notice: Prsant to Section IV, Paragraph R., some Defense Costs are within the Limit of Liability. Any Defense Costs paid nder this coverage will redce the available Limits of Insrance and may exhast them completely. Defense Costs means reasonable and necessary legal fees and expenses incrred by the Company, or by any attorney designated by the Company to defend any Insred, reslting from the investigation, adjstment, defense and appeal of a Claim. Defense Costs incldes other fees, costs, costs of attachment or similar bonds (withot any obligation on the part of the Company to apply for or frnish sch bonds), bt does not inclde salaries, wages, overhead or benefits expenses of any Insred. New Jersey Frad Statement: Any person who incldes any false or misleading information on an application for an insrance policy is sbject to criminal and civil penalties. New York Disclosre Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising ot of incidents, occrrences or alleged Wrongfl Acts or Wrongfl Employment Acts that took place prior to retroactive date, if any, stated on the declarations. This policy shall cover only those claims made against an insred while the policy remains in effect for incidents reported dring the Policy Period or any sbseqent renewal of this Policy or any extended reporting period and all coverage nder the policy ceases pon termination of the policy except for the atomatic extended reporting period coverage nless the insred prchases additional extend reporting period coverage. The policy incldes an atomatic 60 day extended claims reporting period following the termination of this policy. The Insred may prchase for an additional premim an additional extended reporting period of 12 months, 24 months or 36 months following the termination of this policy. Potential coverage gaps may arise pon the expiration for this extended reporting period. Dring the first several years of a claims-made relationship, claims-made rates are comparatively lower than occrrence rates. The insred can expect sbstantial annal premim increases independent overall rate increases ntil the claims-made relationship has matred. North Dakota Frad Statement: Notice to North Dakota applicants Any person who knowingly and with the intent to defrad and insrance company or other person, files an application for insrance or statement of claim containing any materially false information, or conceals for the prpose of misleading, information concerning any fact material thereto, commits a fradlent insrance act, which is a crime and shall also be sbject to a civil penalty. Ohio Frad Statement: Any person who, with intent to defrad or knowing that he is facilitating a frad against an insrer, sbmits an application or files a claim containing a false or deceptive statement is gilty of insrance frad. I nderstand that any material misrepresentation or omission made by me on this application may act to render any contract of insrance nll and withot effect or provide the company the right to rescind it. By acceptance of this policy, the Insred agrees the statements in the application (new or renewal) sbmitted to the company are tre and correct. It is nderstood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage provided herein, for material misrepresentations made by the Insred. It is nderstood and agreed that the statements made in the insrance applications are incorporated into, and shall form part of, this policy. Oklahoma Frad Statement: WARNING: Any person who knowingly, and with intent to injre, defrad or deceive any insrer, makes any claim for the proceeds of an insrance policy containing any false, incomplete or misleading information is gilty of a felony. Oregon Frad Statement: Notice to Oregon applicants: Any person who, with intent to defrad or knowing that he is facilitation facilitating a frad against an insrer, sbmits an application or files a claim containing a false or deceptive statement may be gilty of insrance frad. Any person who knowingly and with intent to defrad any insrance company or other person files an application for insrance or statement of claim containing any materially false information or conceals for the prpose of misleading, information concerning any fact material thereto commits a fradlent insrance act, which is a crime and sbjects sch person to criminal and civil penalties. RHODE ISLAND SPECIAL NOTICE - FOR REAL ESTATE PRODUCTS SOLD IN RHODE ISLAND Rhode Island Disclosre Notice: I nderstand and acknowledge that as respects Discrimination and Lock Box coverage that Claims Expenses are a part of the Limit of Liability. This means that Claims Expenses will redce my limits of insrance and may exhast them completely and shold that occr; I shall be liable for any frther Claims Expenses. Claims Expenses are as defined in Section VII. I also nderstand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations. STSA 8/12 page 4 of 5

8 RHODE ISLAND SPECIAL NOTICE - FOR SUPERTEK AND MICROTEK PRODUCTS SOLD IN RHODE ISLAND Rhode Island Disclosre Notice: I nderstand and acknowledge that Claims Expenses are a part of the Limit of Liability for the MicroTekPak prodct. I also nderstand and acknowledge that Claims Expenses are part of the Limit of Liability for Intellectal Property Claims coverage, if chosen, nder the Technology prodct. This means that Claims Expense will redce my limits of insrance and may exhast them completely and shold that occr, I shall be liable for any frther Claims Expense. Claims Expense is as defined in the DEFINITIONS section of the policy form. Intellectal Property Claims are as defined in Section III of the Broad Form Endorsement for the Technology prodct. I also nderstand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations. RHODE ISLAND SPECIAL NOTICE - FOR EPL, CORPORATE D&O AND NON PROFIT D&O PRODUCTS SOLD IN RHODE ISLAND Rhode Island Disclosre Notice: I nderstand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if the Insred Organization has more than 200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs will redce my limits of insrance and may exhast them completely and shold that occr, I shall be liable for any frther legal Defense Costs and Damages. Defense Costs are as defined in Section III. I also nderstand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations. Tennessee and Virginia Frad Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insrance company for the prpose of defrading the company. Penalties inclde imprisonment, fines and denial of insrance benefits. Utah Notice: I nderstand that Pnitive Damages are not insrable in the state of Utah. There will be no coverage afforded for Pnitive Damages for any Claim broght in the State of Utah. Any coverage for Pnitive Damages will only apply if a Claim is filed in a state which allows pnitive or exemplary damages to be insrable. This may apply if a Claim is broght in another state by a sbsidiary or additional location(s) of the Named Insred, otside the state of Utah, for which coverage is soght nder the same policy Vermont Frad Statement: Any person who knowingly presents a false or fradlent claim for payment of a loss or benefit or knowingly presents false information in an application for insrance may be sbject to fines and confinement in prison. Virginia Notice: This Policy is written on a claims-made basis. Please read the policy careflly to nderstand yor coverage. Yo have an option to prchase a separate limit of liability for the extended reporting period. If yo do not elect this option, the limit of liability for the extended reporting period shall be part of the and not in addition to limit specified in the declarations. If yo have any qestions regarding the cost of an extended reporting period, please contact yor insrance company or yor insrance agent. Statements in the application shall be deemed the insred s representations. A statement made in the application or in any affidavit made before or after a loss nder the policy will not be deemed material or invalidate coverage nless it is clearly proven that sch statement was material to the risk when assmed and was ntre. Virginia Frad Statement: Any person who knowingly and with intent to defrad an insrer, sbmits an Application for insrance or files a claim containing a false or deceptive statement is gilty of insrance frad. Utah Frad Statement: Any person who, with intent to defrad or knowing that he is facilitating a frad against an insrer, sbmits an application or files a claim containing a false or deceptive statement is gilty of insrance frad. Washington Frad Statement: Any person, who, knowing it to be sch: (1) Presents, or cases to be presented, a false or fradlent claim or any proof in spport of sch a claim, for the payment of a Loss nder a contract of insrance; or (2) Prepares, makes, or sbscribes any false or fradlent accont, certificate, affidavit, or proof of Loss, or other docment or writing, with intent that it be presented or sed in spport of sch a claim, is gilty of a gross misdemeanor, or if sch claim is in excess of one thosand five hndred dollars, of a class C felony. Frad Statement (All Other States): Any person who knowingly presents a false or fradlent claim for payment of a loss or benefit or knowingly presents false information in an application for insrance is gilty of a crime and may be sbject to fines and confinement in prison. Retail agency name: License #: Main agency phone nmber: Agency mailing address: City: State: Zip: The signer of this application acknowledges and nderstands that the information provided in this Application is material to the Insrer s decision to provide the reqested insrance and is relied on by the Insrer in providing sch insrance. The signer of this application represents that the information provided in this Application is tre and correct in all matters. The signer of this Application frther represents that any changes in matters inqired abot in this Application occrring prior to the effective date of coverage, which render the information provided herein ntre, incorrect or inaccrate in any way will be reported to the Insrer immediately in writing. The Insrer reserves the right to modify or withdraw any qote or binder issed if sch changes are material to the insrability or premim charged, based on the Insrer s nderwriting gides. The Insrer is hereby athorized, bt not reqired, to make any investigation and inqiry in connection with the information, statements and disclosres provided in this Application. The decision of the Insrer not to make or to limit any investigation or inqiry shall not be deemed a waiver of any rights by the Insrer and shall not estop the Insrer from relying on any statement in this Application in the event the Policy is issed. It is agreed that this Application shall be the basis of the contract shold a policy be issed and it will be attached and become a part of the Policy. New York Frad Statement: Any person who knowingly and with intent to defrad any insrance company or other person files an application for insrance or statement of claim containing any materially false information, or conceals for the prpose of misleading, information concerning any fact material thereto, commits a fradlent insrance act, which is a crime and shall also be sbject to a civil penalty not to exceed five thosand dollars and the stated vale of the claim for each sch violation. Applicant s signatre: Title: Date: Officer of the Board or Property Manager STSA 8/12 page 5 of 5