6. THE BREAKAGE
7. MUST ALWAYS BE COMPLETED
I/We warrant the truth of the answers to the above questions and I/We declare that no information has been withheld and that the amount claimed represents my/our loss arising from the above stated occurrence.
I hereby certify that the information in this application form is true and correct to the best of my knowledge and belief. I authorize Champions Insurance Company to furnish me with a quotation based on the information provided.