First Name*

Last Name*

Mailing Address

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Your Phone Number*

Your Email Address*

All Names on Title

Provide Us With More Details to Received a Faster Application Review (Optional)

I Consent to the Following in Lieu of a Signature
Where (A) an Applicant for this contract gives false particulars to the prejudice of the insurer or knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or (B) the insured contravenes a term of the contract or commits a fraud; or (C ) the Insured willfully makes a false statement in respect of a claim, a claim will become invalid and the Insured’s right to recovery is forfeited.

The Applicants have reviewed all parts of this application and acknowledge that all information is true and correct and understand that this application for insurance is based on the truth and completeness of this information. I have provided personal information in this document and otherwise and I may in future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize Park Insurance Ltd. or the insurance company to collect, use and disclose any of this personal information, subject to the law and to Park Insurance Agency Ltd.’s or insurance company’s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.

I give Park Insurance permission to contact me about its products and services by email, by phone, or via other means. I am aware that I may withdraw my consent at any time.
Yes, I Agree