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No fact, circumstance or situation indicating the probability of a
claim against which indemnification would be afforded by the
proposed insurance is now known by any person(s) or entity(ies)
applying for this insurance other than that which is disclosed in
this application. It is agreed by all concerned that if any
person(s) or entity(ies) to be insured under the policy has any
knowledge of any such fact, circumstance, or situation, any claim
subsequently emanating therefrom shall be excluded from coverage
under the proposed insurance. Additionally, any person who knowingly
and with intent to defraud any insurance company or 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 act, which is against
the law. |
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The applicant, on behalf of the parent organization, declares that
to the best of his/her knowledge the statements herein are true.
Signing of this application does not bind CoverageRx to effect the
insurance, but it is agreed that this application shall be the basis
of the contract should a policy be issued, and this application will
be attached to and become a part of such policy, if issued.
Underwriters are hereby authorized to make any investigation and
inquiry in connection with this application as they may deem
necessary. |
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The completion of this application does not bind the parent
organization. If there is any material change in the answers to
the questions prior to the policy inception date the parent
organization will notify CoverageRx in writing and any
outstanding quotation may be modified or withdrawn. |
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As part of this application, the following is required (where
applicable): |
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- Copy
of the most recently filed Form 5500s for all ERISA plans except
health and welfare plans
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Audited financial statements for all ERISA plans except health
and welfare plans
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Annual report of the parent organization
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