AGREEMENT: I do hereby warrant the truth of any statements and answers mentioned herein,
and that I have not intentionally withheld any information that could influence the judgment of the
company in considering this application for professional liability insurance. I hereby acknowledge
that I have completed the required reporting of claims and incidents to my current carrier.
Erroneous information and/or material misrepresentation will cause immediate rescission of my
AGREEMENT: I understand that the policy being applied for does not cover the liability of others
that I may have assumed under any contract or agreement.
(Note: Your being approved for coverage by the company does not imply acceptance by the
company of any contract or agreement or any liability assumed there under.)
AGREEMENT: I understand that in order to underwrite professional liability insurance, the
company must have access to all possible information concerning my professional conduct and
experience. I hereby authorize and direct any medical society, medical doctor, hospital,
residency program, insurance company, inter-indemnity arrangement, underwriter, and insurance
agent to furnish any information concerning me or my medical practice that the company may
AGREEMENT: Since I understand that the free exchange of information is essential, I agree that
any person or organization furnishing information to the company pursuant to this consent and
direction, together with the agent, employees, or officers of such person or organization, will not
be liable to me in any way for the furnishing such information.
AGREEMENT: I agree that in order to maintain insurance coverage I will comply with the
Company’s established risk management programs and requirements.
Commonwealth of Pennsylvania Fraudulent Insurance Acts: Any person who knowingly and with
intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which in a crime and subjects such person to criminal and civil penalties.