Insurance WC TX Signature Pages

INSURANCE WC TX SIGNATURE PAGES

Applicant / Insured Information

Date of Birth:    Employer Federal EIN (if any):

Policy Details

Policy Number:    Policy Type:

Coverage Amount: $    Deductible: $    Annual Premium: $

Policy Period From:    To:

Coverages / Endorsements

Statutory Workers' Compensation coverage for Texas as required by law

Employers' Liability    Limit: $

Voluntary Compensation    Limit: $

Stop-Gap Liability (where applicable)

Exclusions and Acknowledgements

The Applicant acknowledges and agrees that the policy is subject to the exclusions, conditions and limitations contained in the policy documents and endorsements. The following common exclusions apply unless otherwise endorsed:

Occupational disease exposures not specifically covered by the policy

Injury resulting from intentional acts of the insured or insured's officers

Injury arising from illegal use of controlled substances or alcohol where intoxication is a proximate cause

Beneficiary / Payment Designation

Beneficiary Name:

Relationship to Insured:    Percentage: %

The Applicant acknowledges that any death benefits under this workers' compensation policy will be payable in accordance with Texas law and the terms of the policy and that designation of a beneficiary does not supersede statutory requirements unless expressly permitted by statute and policy language.

Declarations and Certifications

By signing this document, Applicant certifies, represents and warrants that all statements made in the application, policy materials and any attachments are true, complete and accurate to the best of Applicant's knowledge. Applicant understands that material misstatement, omission or concealment of fact may be grounds for denial of coverage or rescission of the policy and may constitute a criminal offense under Texas law.

Applicant expressly authorizes the insurer and its agents to obtain and verify any information necessary for underwriting, rating and premium audit purposes, including but not limited to payroll and employment records, and to share information with other insurers and rating organizations as permitted by law. Applicant understands premiums are subject to audit and final premium may be adjusted based on audited payroll and exposures.

Applicant acknowledges receipt of policy forms and endorsements issued with this policy as of the effective date set forth above and agrees to be bound by their terms and conditions. Applicant further acknowledges that policy cancellation, nonrenewal or modification may occur in accordance with policy terms and applicable Texas law and that notice requirements contained in the policy will be followed.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a criminal act under Texas law. Applicant acknowledges receipt of this notice.

Authorized Representative / Contact for Policy Administration

Acknowledgement of Receipt

Applicant acknowledges receipt of a copy of the completed application, policy declarations and any endorsements issued as of the date of signature. Applicant acknowledges that coverage is effective only upon issuance of policy by the insurer and payment of any required premium unless otherwise agreed in writing.

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