I / We declare hereby that the answers and above statements, whether written of my / our own hand or not, are true and I guarantee / we guarantee that no material has been withheld or misstated and I / We agree that if a policy was established, this proposal form will be attached and form part of and basis for the contract with subscribers. I / We agree that the answers and statements must constitute significant guarantees issued any police. I / We understand that subscribers may declare void any policy issued in the event of misrepresentation, omission or reluctance in
proposal form, whether made intentionally, accidentally or innocently. I was advised / We have been informed by the broker and I / We consent to the collection, the appropriate use and disclosure to third parties any information that could be perceived as a personal information.