$ APPLICANT ACKNOWLEDGEMENT The undersigned authorized officer of the organization declares that, to the best of his/her knowledge, the statements set forth herein are true. Signing of this application does not bind the Insurer to offer, nor the applicant to accept Insurance, but, it is agreed that this form shall be the basis of the contract should a policy be issued, and this form will be attached to and become part of the policy. The undersigned, on behalf of the insured organization, acknowledges that any personal information provided in connection with this application (including but not limited to the information contained in this form) has been collected in accordance with applicable privacy legislation and this information shall only be used or shared by the Company to assess, underwrite and price insurance products and related services, administer and service insurance policies, evaluate and investigate claims, detect and prevent fraud, analyze and audit businesses results and/or comply with regulatory or legal requirements. Applicant Name Title/Position Applicant Signature Date Broker Name Broker Signature
$ APPLICANT ACKNOWLEDGEMENT The undersigned authorized officer of the organization declares that, to the best of his/her knowledge, the statements set forth herein are true. Signing of this application does not bind the Insurer to offer, nor the applicant to accept Insurance, but, it is agreed that this form shall be the basis of the contract should a policy be issued, and this form will be attached to and become part of the policy. The undersigned, on behalf of the insured organization, acknowledges that any personal information provided in connection with this application (including but not limited to the information contained in this form) has been collected in accordance with applicable privacy legislation and this information shall only be used or shared by the Company to assess, underwrite and price insurance products and related services, administer and service insurance policies, evaluate and investigate claims, detect and prevent fraud, analyze and audit businesses results and/or comply with regulatory or legal requirements. Applicant Name Title/Position Applicant Signature Date Broker Name Broker Signature