's submission of this Application does not obligate the Company to issue, or the Applicant
to purchase, a policy. The Applicant
will be advised if the Application for coverage is accepted. The Applicant
hereby authorizes the Company to make any inquiry in connection with this Application.
Notice to Arkansas, Louisiana, Maryland, Minnesota, New Mexico and Ohio Applicants:
Any person who, with intent to defraud or knowing that he/she is facilitating . fraud against an insurer, submits an application or files a claim containing a false, fraudulent or deceptive statement is, or may be found to be, guilty of insurance fraud, which is a crime, and may be subject to civil fines and criminal penalties.
Notice to Colorado Applicants:
It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be to reported to the Colorado Division of Insurance within the Department of Regulatory agencies.
Notice of District of Columbia, Maine, Tennessee and Virginia Applicants:
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Notice to Florida and Oklahoma Applicants:
Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony (in Oklahoma) or a felony of the third degree (in Florida).
Notice to Kentucky Applicants:
Any person who, knowingly and with intent to defraud any insurance company or other person files application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which is a crime.
Notice to New Jersey Applicants:
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Notice to Oregon and Texas Applicants:
Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.
Notice to Pennsylvania and New York Applicants:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject: to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation (in New York) or criminal and civil penalties (in Pennsylvania).
ACKNOWLEDGEMENT, REPRESENTATIONS, & WARRANTIES
The applicant is authorized by and acting on behalf of all persons concerned seeking insurance, has read and understands this application and declares all statements set forth herein are true, complete, and accurate.
The applicant further declares and represents that any happening, incident, or event taking place prior to the effective
date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made herein will
immediately be reported in writing to the insurer and the insurer may withdraw of modify any outstanding quotations
and/or authorizations to bind the insurance or the policy, if a policy is issued.
The applicant acknowledges and agrees that the submission to and the insurer’s receipt of such written report, prior to the
inception of the policy applied for, is a condition precedent to coverage.
The applicant by signing this application hereby authorizes, but does not require, the underwriters and/or their
representatives to contact any prior insurer and obtain any details or prior loss information or obtain any other
information from any source including consumer credit information, which the underwriters deem appropriate in the
underwriting of the insurance applied for by this application.
The applicant agrees that this application shall be the basis of the contract should a policy be issued and it will be attached
to and become a part of the policy.
The applicant acknowledges and agrees that the affixing of the applicant’s signature to this application does not bind
either the underwriter or the applicant to complete this insurance.
By placing the initials of the applicant in the box below, the applicant acknowledges acceptance of the above, and understands that the initials carry the effect of a signature.