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Municipal Entity Underwriting Application

No fact, circumstance or situation indicating the probability of a claim or action is now known to any person proposed for this insurance; and it is agreed by all concerned that if there be knowledge of any such fact, circumstance or situation, any claim or action subsequently emanating there from shall be excluded from coverage under the insurance for here which being applied.  The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking insurance, has read and understands this application, and declares all statements set forth herein are true, complete and accurate.

The undersigned further declares and represents that any occurrence taking place prior to the inception of the policy for which being applied, which may render inaccurate, untrue or incomplete any statement made herein will immediately be reported in writing to the company.  The undersigned acknowledges and agrees that the submission and the company’s receipt of such report, prior to the inception of the policy for which being applied, is a condition precedent to coverage.

The undersigned acknowledges and agrees this application contains requests for information and requests for data on a range of exposures, but such requests do not imply that coverage is afforded in the policy for which is being applied.

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34 of 3410/23/2007

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