DISCLAIMER
II INSURANCE INCORPORATED
Disclaimer
Insured - #
Company - #
Premium Quoted - $#
Effective Date -#
The above quotation is with an insurance company that does not meet our standard and WE WILL ACCEPT NO RESPONSIBLITY WHATSOEVER FOR THE INSURANCE COMPANY'S OBLIGATIONS.
Yours very truly,
Insurance, Incorporated
Acknowledgment:
I have read the above, understand it and want you to write the above coverage, as quoted.
_______________________________________________________________________
Date - _____________________________________
Acknowledgment, Consent, and Waiver Form
1. The undersigned has made application through Roger Bouchard Insurance, Inc. for insurance concerning the following:
___________________________________________________________________________
___________________________________________________________________________
2. Due to one or more of the reasons checked below, the insurance to be issued for the benefit of the undersigned will be issued by an insurance company which has a rating less than an 'A' rating as determined by BEST'S AGENTS GUIDE TO INSURANCE COMPANIES.
___ Premium amount for insurance contract issued by insurance company with an 'A' or better rating as determined by BEST'S AGENTS GUIDE TO INSURANCE COMPANIES is higher than the insurance contract selected by the undersigned.
___ No companies with an 'A' or better rating as determined by BEST'S AGENTS GUIDE TO INSURANCE COMPANIES will insure the undersigned or will insure the risks the undersigned desires to insure.
___ There are no companies with an 'A' or better rating as determined by BEST'S AGENTS GUIDE TO INSURANCE COMPANIES, which will insure the risks that the undersigned desires to insure.
___ Other: __________________________________________________________________
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3. The undersigned hereby acknowledges and affirms that the undersigned has been informed that the insurance company that will issue the policy requested by the undersigned will not be a company with an 'A' or better rating. The undersigned may experience some problems or difficulties in its dealings with such an insurance company. Nevertheless, the undersigned hereby requests of and grants the authority to Roger Bouchard Insurance, Inc., to seek the issuance of an insurance contract from the insurance company named below, and the undersigned does hereby release Roger Bouchard Insurance, Inc.; its employees, and its independent contractors from any and all liabilities, expenses, costs, fees, or any other loss that the undersigned may experience rising out of, or in any way relating to the undersigned's dealings with and contractual agreements with the insurance company named below, which is issuing the insurance contract in favor of the undersigned.
4. The undersigned hereby acknowledges that it has received no assurances from Roger Bouchard Insurance, Inc., its employees, or its independent contractors that the below-mentioned insurance company, which is issuing the insurance contract in favor of the insured, can fully perform its obligation under such contract.
Witnesses:
___________________________ _________________________
(INSURED)
___________________________ Date:____________________
Insurance Company: ______________________________________________
Best's Rating: __________