I declare that the information provided in connection with this proposal, whether in my own hand or not, is true and I have not withheld any material facts*. I understand that non-disclosure or misrepresentation of a material fact* may entitle underwriters to void the insurance. *A material fact is one likely to influence acceptance or assessment of this proposal by underwriters; if you are in any doubt as to whether a fact is material or not you must disclose it. This proposal and the information provided in connection therewith contain statements upon which underwriters will rely in deciding to accept this insurance. Should a contract of insurance be concluded this proposal will form the basis of the insurance.
