HomeMy WebLinkAbout*Other - Renew..)A-.NIES RIVER
GROUP
DECLARATION OF NO KNOWN LOSS
NO MATERIAL CHANGE
ATTENTION: JAMES RIVER INSURANCE COMPANY
POLICY NUMBER: TBD
APPLICANT/INSUREDNAME: Darcy A Sander ARNP PMHNP BC
CORPORATE NAME: N/A
The Applicant/Insured declares and warrants that after diligent inquiry, no
claims or suits have been made against the applicant insured, or, against the
corporate entity or any predecessor corporate entity to the date of this letter.
Also, no Applicant, Named Insured(s), Additional Insured(s)or any person or
entity which qualifies as an Insured has any knowledge of any incident,
circumstance, act, error, omission or personal injury which may give rise to a
claim being made against the Applicant, Insured, or against the corporate
entity or any predecessor corporate entity.
The Applicant/insured declares and warrants that the statements set forth
herein are true and no material facts have been omitted or misstated. The
Applicant/insured further declares and recognizes that this declaration is
material to James River's acceptance of the risk and that Underwriters
reserve the right to rescind coverage of any Policy that is issued as a result of
this application if the statements set forth herein and any attachments are
erroneous for any reason.
SIGNATURE:
PRINT NAME: Dell Anderson, M.Ed, LMHC Cindy Carter
TITLE: Executive Director Chair, Board of County Commissioners
DATE: 10/21/2021 /G) - 2-/ - 2 (