THE UNDERSIGNED IS AUTHORIZED BY THE APPLICANT AND DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE PROGRAM AND/OR INSURANCE, HE/SHE WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE PROGRAM AND/OR INSURANCE, IMMEDIATELY NOTIFY THE PROGRAM ADMINISTRATOR OR INSURER OF SUCH CHANGES, AND THE PROGRAM ADMINISTRATOR OR INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE PROGRAM AND/OR INSURANCE.
SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BECOME PART OF THE POLICY.
ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. THIS APPLICATION IS ATTACHED TO THE POLICY AT THE TIME OF ITS DELIVERY. PROVIDED, HOWEVER, THIS PARAGRAPH DOES NOT APPLY IN THE STATE OF UTAH.
Furthermore, and in respect of additional and related program deliverables, the undersigned declares that he/she understands and agrees to all of the terms and conditions provided in the Customer Agreement located at: http:// biz.identityfraud.com/pages/customer-agreement and to the following statement: In respect of the Data Risk Liability insurance, I acknowledge that the coverage is provided on a "claims made" basis. I also specifically confirm that I will or that I have read, understood and agree to my state insurance disclosure, which relates to Excess and/or Surplus Lines insurance, which in summary, states the insurance company with which the Data Risk Liability coverage is being placed is not licensed by my state and is not subject to its supervision. In the event of insolvency of the insurance company, losses under the policy will not be paid by any state insurance guaranty or insolvency fund. Additionally, the coverage is provided pursuant to my acceptance into and continued active status in the Data Theft Risk Purchasing Group and/or related RPG. I understand there may be a nominal fee of $1.00 per term paid to the RPG from the proceeds of my purchase.