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The information provided in this application is true and accurate to the best of my knowledge. I understand that any false or misleading information, including but not limited to intentional misrepresentation or fraud, may result in the denial of coverage, cancellation of the policy, or legal action. I acknowledge that fraudulent information may lead to criminal charges and potential liability for damages. By signing this application, I certify that all information provided is correct and complete.

By printing my full name on this form, I confirm to be the named insured authorizing this request for insurance.