Application for Quote

This is a preliminary application for purpose of obtaining a quotation. Such quotation will be subject to submission and approval of underwriting information submitted with the formal application. Receipt of a quotation based on this application does not bind coverage.

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Completion of this Short Form Application and our issuance of a quotation on this basis assumes that you or the entity to be insured has no issues (incidents, suits, fraud, etc.) which would make you ineligible to participate in this program. Final approval is subject to review of Full Application.

Buy submitting this form you understand the coverage provided is subject to a program aggregate limit as well as sub-limits per certificate holder as per the master policy on file with the Company.

Louisiana Revised Statute Note 40:1424, provides, in part, the following: "B. Any person who knowingly presents a false or fraudulent claim for payment of a toss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison"

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