I/We hereby declare that the above particulars and statements are true, correct and complete and contain all information known to me/us affecting the risk to be insured, and that this and any other written statement made by me/us or on my/our behalf for the purpose of insurance shall be the basis of and incorporated in the contract between me/us and TiB Insurance Brokers (hereinafter called the Company) shall be promissory
I/We further agree to accept insurance on terms and conditions set forth in the Company’s policy, and particularly undertake to notify the company immediately of any alteration in the risk. We further agree that liability shall attach to the Company from the date of receipt of the premium payment.
WARNING: INSURANCE FRAUD IS A CRIME
PLEASE NOTE: ORIGINAL SIGNED PROPOSAL FORM MUST BE SUBMITTED TO TIB INSURANCE BROKERS SUBJECT TO APPROVAL