GENERAL FRAUD STATEMENT
(not applicable in Colorado, Hawaii, Nebraska, Ohio, Oklahoma, Oregon, Utah and Vermont) Any person who knowingly and with intent
to defraud any insurance company or another person files an application for insurance 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 subjects the person to criminal and civil penalties. In the District of Columbia, Louisiana, Maine, Tennessee and Virginia,
insurance benefits may also be denied.
NOTICE TO COLORADO APPLICATIONS: THIS NOTICE IS A PART OF YOUR APPLICATION FOR PROFESSIONAL LIABILITY
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
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
NOTICE TO HAWAII APPLICANTS:
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment or both.
NOTICE TO OHIO APPLICANTS:
Any person who, with intent to defraud or knowing that he/she is facilitation a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS:
WARNING: A person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO UTAH APPLICANTS:
For your protection, Utah law requires the following to be included in this application: "Any person who knowingly presents false or
fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits,
or submits a false or fraudulent report for billing for health care fees or other professional services is guilty of a crime and may be subject
to fines and confinement in state prison.
NOTICE TO 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.
THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE APPLICANT AGREES THAT IF THE INFORMATION
SUPPLIED ON THE APPLICATION BY THE APPLICANT CHANGES BETWEEN THE DATE OF THE APPLICATION AND THE EFFECTIVE DATE OF
INSURANCE, APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES AND THE COMPANY MAY WITHDRAW OR
MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.
This application is understood to be an inducement to the issuance of a policy of insurance by the Company. The undersigned hereby
authorizes the Company to obtain information necessary for evaluation in determining acceptability including but not limited to motor
vehicle reports, credit reports and physical inspection.