Common use of Signature and Acknowledgement Clause in Contracts

Signature and Acknowledgement. Insured has signed this agreement and received a copy of it. If Insured is a corporation, the person signing is an officer of that corporation authorized to sign this agreement. If the Insured is not a corporation, all Insureds listed in any policy have signed. LIABILITY. Insured understands and agrees that FIRST has no liability to Insured or any person or entity upon the exercise of FIRST's right of cancellation, except in the event of willful or intentional misconduct by FIRST. AGENT OR BROKER REPRESENTATIONS AND WARRANTIES SIGNATURES GENUINE. To the best of our knowledge, the Insured's signature is genuine. AUTHORIZATION/RECOGNITION. The Insured has authorized this transaction. Both the Insured and the Agent/Xxxxxx recognize the security interest granted herein, pursuant to which the Insured assigns to FIRST all unearned premium, dividends and certain loss payments. Upon cancellation of any of the policies listed in the Schedule of Policies, the Agent/Xxxxxx agrees to immediately pay FIRST all unearned commissions and all unearned premiums, dividends and loss payments received. If such funds are not remitted to FIRST within 10 days of receipt by the Agent/Xxxxxx, the Agent/Xxxxxx agrees to pay FIRST interest on such funds at the maximum rate allowed by applicable law. POLICIES EFFECTIVE/PREMIUMS CORRECT. The policies listed in the Schedule of Policies are in full force and effect, and the premiums are correct as listed. INSURED HAS THIS DOCUMENT. The Insured has been given a copy of this agreement. NO INSOLVENCY. To the best of our knowledge, neither the Insured nor the insurance companies are insolvent or involved in a bankruptcy or similar proceeding as debtor, except as clearly indicated on page 1 of this agreement. FOR THE SCHEDULED POLICIES, AGENT OR BROKER WARRANTS THAT: DEPOSIT/PROVISIONAL PREMIUMS. Any Audit or Reporting Form policies or policies subject to retrospective rating included in this agreement are noted below in section (a). The deposit or provisional premiums for these policies are not less than the anticipated premiums to be earned for the full term of the policies.

Signature and Acknowledgement. Insured has signed this agreement I have received and received reviewed a copy of itthe Declaration of Trust (The Master Trust) prior to the signing of this Joinder Agreement. If Insured is a corporationI have also read the policies and procedures and the master trust and acknowledge that I understand the contents therein. I also understand that said documents may be amended from time to time. By signing below, the person signing Donor acknowledges that the Beneficiary is an officer disabled as defined in Social Security Law Section 1614 (a) (3) Under penalty of that corporation authorized to sign this agreement. If the Insured is not a corporationxxxxxxx, all Insureds listed statements made in any policy have signed. LIABILITY. Insured understands this document are true and agrees that FIRST has no liability accurate to Insured or any person or entity upon the exercise of FIRST's right of cancellation, except in the event of willful or intentional misconduct by FIRST. AGENT OR BROKER REPRESENTATIONS AND WARRANTIES SIGNATURES GENUINE. To the best of our my knowledge. EVERFUND POOLED TRUST is a trust authorized to be used by individuals with disabilities pursuant to federal and state law. By agreeing to accept a Xxxxx's property pursuant to this Joinder Agreement, EVERFUND POOLED TRUST agrees only to manage the Insuredtrust funds in accordance with the terms of the Master Trust Agreement and in compliance with applicable federal and state law and regulation. It is the sole responsibility of the Donor and/or the Donor's signature representative to determine whether the Donor is genuine"disabled" as that term is defined under federal law, and to determine the impact that a transfer of property to the EVERFUND POOLED TRUST will have on the Donor's continuing eligibility for government benefit programs. AUTHORIZATION/RECOGNITIONEVERFUND POOLED TRUST is not assuming any responsibility as counsel for the Donor or Beneficiary, or providing any legal advice as it relates to the consequences of a transfer of property to the EVERFUND POOLED TRUST. The Insured has Trustees in their discretion may require an intermediary to assist in the administration of the Beneficiary's sub-trust account. The party authorized this transactionto speak with us on your behalf or the intermediary must notify EVERFUND POOLED TRUST immediately upon your death and will be required to provide us with a certified death certificate. Both An individual requesting and/or receiving disbursements in contravention of the Insured Master Trust Agreement and the AgentJoinder Agreement will be required to repay the amount disbursed. Signature of Donor/Xxxxxx recognize the security interest granted herein, pursuant Beneficiary or POA/Guardian Relationship to which the Insured assigns to FIRST all unearned premium, dividends and certain loss payments. Upon cancellation Beneficiary Print Name Date [If signed by a Power of any of the policies listed in the Schedule of Policies, the Agent/Xxxxxx agrees to immediately pay FIRST all unearned commissions and all unearned premiums, dividends and loss payments received. If such funds are not remitted to FIRST within 10 days of receipt by the Agent/Xxxxxx, the Agent/Xxxxxx agrees to pay FIRST interest on such funds at the maximum rate allowed by applicable law. POLICIES EFFECTIVE/PREMIUMS CORRECT. The policies listed in the Schedule of Policies are in full force and effect, and the premiums are correct as listed. INSURED HAS THIS DOCUMENT. The Insured has been given Attorney or Guardian attach a copy of the POA/Guardianship documents.] STATE OF NEW YORK ) ) SS:. COUNTY OF ) On this agreementday of , 201 , before me, the undersigned, a Notary Public in and for said State, personally appeared, . NO INSOLVENCY. To Personally known to me or proved to me on the best basis of our knowledge, neither the Insured nor the insurance companies are insolvent or involved in a bankruptcy or similar proceeding as debtor, except as clearly indicated on page 1 of this agreement. FOR THE SCHEDULED POLICIES, AGENT OR BROKER WARRANTS THAT: DEPOSIT/PROVISIONAL PREMIUMS. Any Audit or Reporting Form policies or policies subject to retrospective rating included in this agreement are noted below in section (a). The deposit or provisional premiums for these policies are not less than the anticipated premiums satisfactory evidence to be earned for the full term individual whose name is subscribed to within the instrument and acknowledged to me that he/she executed the same in his/her capacity and that by his/her signature on the instrument, the individual or the person upon behalf of which the policies.individual acted, executed the instrument. Notary Public FOR OFFICE USE ONLY TRUSTEE DATE DATE RECEIVED DATE COMPLETED DATE ACCEPTED

Signature and Acknowledgement. Insured has signed this agreement I have received and received reviewed a copy of itthe Declaration of Trust (The Master Trust) prior to the signing of this Joinder Agreement. If Insured is a corporationI have also read the policies and procedures and the master trust and acknowledge that I understand the contents therein. I also understand that said documents may be amended from time to time. By signing below, the person signing Donor acknowledges that the Beneficiary is an officer disabled as defined in Social Security Law Section 1614 (a) (3) Under penalty of that corporation authorized to sign this agreement. If the Insured is not a corporationperjury, all Insureds listed statements made in any policy have signed. LIABILITY. Insured understands this document are true and agrees that FIRST has no liability accurate to Insured or any person or entity upon the exercise of FIRST's right of cancellation, except in the event of willful or intentional misconduct by FIRST. AGENT OR BROKER REPRESENTATIONS AND WARRANTIES SIGNATURES GENUINE. To the best of our my knowledge. EVERFUND POOLED TRUST is a trust authorized to be used by individuals with disabilities pursuant to federal and state law. By agreeing to accept a Donor's property pursuant to this Joinder Agreement, EVERFUND POOLED TRUST agrees only to manage the Insuredtrust funds in accordance with the terms of the Master Trust Agreement and in compliance with applicable federal and state law and regulation. It is the sole responsibility of the Donor and/or the Donor's signature representative to determine whether the Donor is genuine"disabled" as that term is defined under federal law, and to determine the impact that a transfer of property to the EVERFUND POOLED TRUST will have on the Donor's continuing eligibility for government benefit programs. AUTHORIZATION/RECOGNITIONEVERFUND POOLED TRUST is not assuming any responsibility as counsel for the Donor or Beneficiary, or providing any legal advice as it relates to the consequences of a transfer of property to the EVERFUND POOLED TRUST. The Insured has Trustees in their discretion may require an intermediary to assist in the administration of the Beneficiary's sub-trust account. The party authorized this transactionto speak with us on your behalf or the intermediary must notify EVERFUND POOLED TRUST immediately upon your death and will be required to provide us with a certified death certificate. Both An individual requesting and/or receiving disbursements in contravention of the Insured Master Trust Agreement and the AgentJoinder Agreement will be required to repay the amount disbursed. Signature of Donor/Xxxxxx recognize the security interest granted herein, pursuant Beneficiary or POA/Guardian Relationship to which the Insured assigns to FIRST all unearned premium, dividends and certain loss payments. Upon cancellation Beneficiary Print Name Date [If signed by a Power of any of the policies listed in the Schedule of Policies, the Agent/Xxxxxx agrees to immediately pay FIRST all unearned commissions and all unearned premiums, dividends and loss payments received. If such funds are not remitted to FIRST within 10 days of receipt by the Agent/Xxxxxx, the Agent/Xxxxxx agrees to pay FIRST interest on such funds at the maximum rate allowed by applicable law. POLICIES EFFECTIVE/PREMIUMS CORRECT. The policies listed in the Schedule of Policies are in full force and effect, and the premiums are correct as listed. INSURED HAS THIS DOCUMENT. The Insured has been given Attorney or Guardian attach a copy of the POA/Guardianship documents.] STATE OF NEW YORK ) ) SS:. COUNTY OF ) On this agreementday of , 201 , before me, the undersigned, a Notary Public in and for said State, personally appeared, . NO INSOLVENCY. To Personally known to me or proved to me on the best basis of our knowledge, neither the Insured nor the insurance companies are insolvent or involved in a bankruptcy or similar proceeding as debtor, except as clearly indicated on page 1 of this agreement. FOR THE SCHEDULED POLICIES, AGENT OR BROKER WARRANTS THAT: DEPOSIT/PROVISIONAL PREMIUMS. Any Audit or Reporting Form policies or policies subject to retrospective rating included in this agreement are noted below in section (a). The deposit or provisional premiums for these policies are not less than the anticipated premiums satisfactory evidence to be earned for the full term individual whose name is subscribed to within the instrument and acknowledged to me that he/she executed the same in his/her capacity and that by his/her signature on the instrument, the individual or the person upon behalf of which the policies.individual acted, executed the instrument. Notary Public FOR OFFICE USE ONLY TRUSTEE DATE DATE RECEIVED DATE COMPLETED DATE ACCEPTED