Insurance Assurance Application

INSURANCE ASSURANCE APPLICATION

RECITALS

WHEREAS, Applicant Name: (the "Applicant") seeks assurance of insurance coverage and/or financial guarantee for obligations described in this Application; and

WHEREAS, Assurer Company: (the "Assurer") is willing to consider issuing assurance subject to the terms, representations and covenants set forth herein.

WHEREAS, the Applicant requests issuance of assurance to secure performance or other obligations arising under the Scope of Work and Policy Details contained below.

APPLICANT INFORMATION

Individual Corporation LLC Partnership Other

ASSURER / PROVIDER INFORMATION

COVERAGE REQUEST & POLICY DETAILS

Type of Assurance (select all applicable):
Performance Bond Payment Bond Surety General Liability Other

Proposed Effective Date:     Proposed Expiration Date:

PAYMENT TERMS

Premium Amount (initial deposit): .

Payment Schedule: . Applicant shall pay premiums in accordance with the Assurer's billing procedures. Failure to pay premium when due constitutes a material breach permitting suspension or cancellation of assurance in accordance with the terms below.

Late Fee and Interest: Any past due amount shall bear interest at a rate of 1.5% per month, or the maximum rate permitted by applicable law, whichever is lower. Applicant agrees to pay all collection costs, including reasonable attorney fees, incurred by the Assurer in enforcing payment.

ACH/Bank Transfer Check Credit Card

TERM AND TERMINATION

Term Commencement Date: .     Term Expiration Date: .

Notice Period for Termination: Either party may terminate this assurance upon written notice delivered at least days prior to the intended termination date. Termination for nonpayment or material breach may be effective immediately where permitted by applicable law and consistent with policy provisions.

Effect of Termination: Termination does not relieve the Applicant of liability for obligations incurred prior to the effective date of termination nor entitle Applicant to refund of premiums except as expressly provided by the Assurer's policy or by applicable statute.

REPRESENTATIONS, WARRANTIES, AND CERTIFICATIONS

Applicant represents and warrants that all information provided in this Application is true, complete and correct to the best of Applicant's knowledge. Applicant authorizes the Assurer to verify any information and to obtain reports and references as necessary to assess risk. Applicant understands that misrepresentation, omission or failure to disclose material facts may be grounds for denial, rescission, or cancellation of assurance.

Applicant further certifies that there are no pending or threatened adjudications, claims, or defaults related to the obligations for which assurance is requested unless otherwise disclosed in writing below.

CONFIDENTIALITY

Except as required by law or regulatory authority, the Assurer and Applicant agree to maintain in confidence all non-public business, technical and financial information exchanged in connection with this Application and any assurance subsequently issued. Confidential information shall not be disclosed to third parties except to affiliates, reinsurers, advisors or as necessary to effect the assurance, provided such third parties are bound to confidentiality obligations at least as protective as those set forth herein.

GOVERNING LAW

This Application, and any assurance issued in reliance upon it, shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles. Venue for disputes shall lie in the competent courts of that State, unless mandatory law requires otherwise.

ENTIRE AGREEMENT

This Application, together with any cover note, policy, endorsement, and the Assurer's written terms, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous negotiations, proposals and agreements, whether written or oral. No amendment is effective unless executed in writing by authorized representatives of both parties.

AUTHORIZATION

By signing below, Applicant certifies the truthfulness of all statements made in this Application, authorizes the Assurer to obtain and share information as necessary to evaluate the request, and acknowledges that issuance of assurance is subject to the Assurer's underwriting approval and execution of binding documents.

Sign Now