After reseasonable inquiry, the below signatory
on behalf of the Applicant represents and warrants that the information
submitted to the company in this application, and any supplementary information
thereto, is true, complete and accurate and that no material or relevant
fact has been suppressed or missstated as of the date such information
is submitted to the company. The applicant agrees to advise the company
of any changes to the information provided in this application including
but not limited to any change in the information provided in this applicaiton
including but not limited to any change in the professional services or
contraction opertaions specifially described in this application, notices
of any claim or of any ptential claim, or of any circumstances that may
give rise to a claim unti the company binds a policy or until a company
declines to bind a policy. If a policy is issued by the company, this
application shall become part of the policy and shall be deemed to be
attached to the policy.
Any misrepresentation, non-discolusre, concealment, suppression or misstatement
or breach of warranty in this application or supplementary information
thereto shall be construed against the applicant.
Completion of this application does not bind coverage.
Notice to Applicant - State Fraud Warnings
The meaning assigned to any defined term used in this Application shall
be equally applicable to both the singular and the plural forms of such
term, and words denoting any gender shall include all genders. Where a
word or phrase is defined herein, each of its other grammatical forms
shall have a corresponding meaning. The Applicant represents that the
above statemens are true and correct to the best of the Applicant's knowledge
and that material or relevant facts have bot been suppressed or mistaken.
Completion of this form does not bind coverage. This Application shall
become part of the policy, if any issued by the company and shall be deemed
to be attached to the policy.
Notice to Arkansas Applicant
Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in any application
for insurance is guilty of a crime and may be subject to fines and confinement
in prison.
Notice to Colorado Applicant
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 infor-mation 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 agencies.
Notice to Florida Applicant
Any person who knowingly and with intent to injure, defraud, or deceive
any insurer files a statement of claim or an application con-taining any
false, incomplete, or misleading information is guilty of a felony of
the third degree.
Notice to Florida Applicant
Any person who knowingly and with intent to injure, defraud, or deceive
any insurer files a statement of claim or an application containing any
falst, incomplete, or misleading information is guilty of a felony of
the third degree.
Notice to Kentucky Applicant
Any person who knowingly and with intent to defraud any insurance company
or other person files an application for insurance con-taining 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.
Notice to Louisiana Applicant
Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement
in prison.
Notice to Maine Applicant
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 a denial of insurance benefits.
Notice to Nebraska Applicant
No misrepresentation or warranty made by the insured or on his behalf
in the negotiation or application of this policy or contract of insurance
shall defeat or void the policy or contract or effect the company's obligation
under this policy or contract unless such misrepresentation or warranty:
1) Was material;
2) Was made knowly with the intent to deceive;
3) Was relied and acted upon by the company; and;
4) Deeived the company to it injury.
The breach of a warranty or condition in any contract or policy of insurance
shall not void the policy or allow the company to avoid liablity unless
such breach exists at the time of the loss and contributes to the loss.
Notice to New Jersey Applicant
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 New Mexico Applicant
Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents falst information in an application
for insurance is guilty of a crime and may be subject to civil and criminal
penalties.
Notice to New York Applicant
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.
Notice to Ohio Applicant
Any person who with intent to defraud or knowingly that he/she is facilitating
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 Applicant
WARNING: Any 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 of Pennsylvania Applicant
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 subjects such person
to criminal and civil penalties.
Notice to Tennessee Applicant
It is a crime to knowingly provide false, incomplete or misleading information
to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fine and denial of coverage.
Notice to Utah Applicant
Any person who knowingly presents false or fraudulent underwriting information,
files or auses to be filed a false or fraudulent claim for disability
compensaiton or medical benefits, or submits a flase or fraudulent report
of billing for health care fees or other professional services if guilty
of a crime and may be subject to fines and confinement in state prison.
Notice to Virginia Applicant
It is a crime to knowingly provide false, incomplete or misleading information
to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fine and denial of insurance benefits.
Notice to Washington D.C. Applicant
It is a crime to provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other person. Penalties
include imprisonment and/or fine. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided
by the
applicant.
Notice to All Other State 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 false information or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime in certain jurisdictions. |