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Business Risk Partners, Alternative Dispute Resolution Professionals Liability Application, 11 /04 <br />Notice to Applicant: Please Read Carefully. <br />Warranty: The applicant warrants that the Information contained herein is true as of the date of this application Is <br />executed and understands that it shall be the basis of the policy of insurance and deemed Incorporated herein if the <br />Insurers accept this application by issuance of a policy. It is understood and agreed that this warranty constitutes a <br />continuing obligation to report to the Insurers, as soon as possible, any material change in the circumstances of the <br />applicant's business, including but not limited to size of the firm, area of business engaged in by the firm and <br />Information contained on each Supplemental application submitted by the applicant. <br />Any person who knowingly and with intent to defraud any insurance company or any other person files an application for <br />insurance containing any materially false information or conceals for the purpose of misleading, the Information <br />concerning any fact material thereto commits a fraudulent insurance act, which is a crime. <br />THE APPLICATION MUST BE SIGNED "D DATED BY AN OWNER, OFFICER OR PARTNER. <br />Applicant Signature: <br />Name and Title (Please Print): <br />Date (Mo-Day -Yr): ZZ. e7�—p ') <br />