The undersigned being authorized by and acting on
behalf of the applicant and all persons or concerns seeking
insurance, has read and understands this proposal and declares all
statements set for herein are true, complete, and accurate.
The undersigned further declares and represents that any occurrence
or event taking place prior to the inception of the policy applied
for which may render inaccurate, untrue, or incomplete any statement
made herein will immediately be reported in writing to the insurer.
The undersigned acknowledges and agrees that the
submission and the insurer's receipt of such report prior to the
inception of the policy applied for is a condition precedent to
It is understood and agreed that the completion of
this application shall not be binding either to the Proposed Insured
or to the Company until accepted by the Company or Companies.
Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly
provides false information on an application for insurance may be
guilty of a crime, and may be subject to civil fines and criminal
I certify that the above information is true and
coverage is not applicable until accepted by DHC Insurance, L.L.C.