READ CAREFULLY BEFORE COMPLETING. YOU COMPLETE
ONLY 1 OR 2.
Insurance coverage is only provided if the insurance company is put on
notice of a possible claim through one of its authorized agents or
Emergency First Response. |
Section 1
By checking
this box ...
I have no knowledge of
any incident, accident, occurrence, act, error, or omission that
might lead to, or has already lead to, a legal action or claim. I understand that I must
report any incident, accident, occurrence, act, error, or omission
to any previous insurer and that this policy does not cover any
known incidents, accidents, occurrences, acts, errors, or omissions.
By applying for
this insurance, I hereby authorize Emergency First Response to release information to the
insurance company pertinent to the investigation of insurance claims.
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Section 2
By checking
this box ...
I
have knowledge of an incident, accident, occurrence, act, error, or
omission, that might lead to a legal action or claim for my
supervisory or instructional activities. I understand that I must
report any incident, accident, occurrence, act, error, or omission
to any previous insurer and that this policy does not cover any
known incidents, accidents, occurrences, acts, errors, or omissions.
By applying for this
insurance, I hereby authorize EFR to release information to the
insurance company pertinent to the investigation of insurance claims.
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