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Pursuant to section 403.11 of the Texas Insurance Code: I hereby give notice that I am claiming the right to subscribe to a policy or policies of insurance pursuant to my right to purchase insurance under the insurance code. I hereby authorize you or the insurance company or insurers named above to cancel any insurance policy issued to me on the basis of the representations made by me on this form if such representations are untrue at the time of any request for such insurance to be cancelled. I understand that I am bound by the representations made by me on this application or any waiver or amendment given by me. I agree that if any such representations are not true when made, such statements may be used against me in any action arising out of this application or waiver or amendment. I further agree that as a condition of receiving the insurance, I will be bound by all the terms of this application or waiver or amendment. I hereby expressly assume and contract that the above named insurers are acting on their own behalf and are not agents of each other and that I am not required to join in the contract of insurance for any insurer.
I represent: IN THE HEARING OF this matter, I make oath that I have read and fully understand the provisions of Chapter 546 of the Texas Insurance Code and the Tex-as Insurance Code and the rules and regulations of the Texas Department of Insurance relating to the filing of this application.
My address is ____________________________________________.
I understand and agree to the terms and conditions of this application (which terms and conditions include any terms and conditions on which the state of Texas denies me the right to purchase insurance and I have expressly assumed and contracted).
Applicant Signature: ____________________________________ Date: ____________________
Insurance Agent Signature: _____________________ Date: __________
Applicant = _______________________
Insurance Agent = _______________________
Please be sure to read the following carefully:
It is the policy of the Texas Department of Insurance that a new application for insurance shall be filed when any material fact in the application is changed or when the policyholder has been changed.
The Texas Department of Insurance and the insurer have the right to cancel the policy if you fail to file an application for a policy within thirty days of the effective date of the policy, or if you fail to pay any premium due within ten days of the due date of the premium or if any material fact in the application is untrue at the time of the application.