If Other Please Specify
Loss Payable: Name of All Lender(s) and Lessor(s), if any, which must be named in "Loss Payable" Clause
The insured represents that the information furnished in this application is complete, true and correct. Any misrepresentation, omission, concealment or incorrect statement of material fact, in the application or otherwise, shall be grounds for rescission of any policy issued in reliance upon such information. I hereby declare that to the best of my knowledge and belief, the above statements and particulars are true, that I have not suppressed or misstated any material facts and I agree that this declaration shall form the basis of the insurance contract prepared on my behalf by the Insurer.