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I/we declare that the information provided above is true, correct and complete and that it contains all information known to me/us that will affect the risk to be insured. This statement, and any other written statement made by me/us or on my/our behalf for the purpose of insurance, will be the basis of and will be incorporated in the contract between me and the Insurance Company that I have chosen from the panel of Insurance Companies provided to me.
I/we further agree to accept insurance on the terms and conditions set forth in the Company's policy and undertake to notify the Company immediately if the risk changes. I/we also agree that this agreement will take effect from the date of receipt of the premium payment.