Name of organization

How long have you had insurance?

Insurance Type

Any lapse in coverage?
Yes
No

If yes describe

Have you had any claims or incidents during the current year and/or Prior 4years
Yes
No

If there are any claims (even those closed without payment) for the current year and/or prior 4 years, please list ALL claims below:

Date of loss

Insured represents that no claims of any type have been made by the insured or by any claimant against the insured in the last 5 years and that the insured is aware of no set of facts incidents ,or the accident in the last 5 year that might give rise to a claim or lawsuit. The insured has not been denied converage or had converage cancelled or non-rewened by any insurance company in the last 5 year

Date Completed:

Title :

Name of person completing

Signature: