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EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 1 of 11
Before
YOU
begin,
You
should KNOW
• Many of the bolded words in this application have specific meanings:
“You,” “your” and “yourself” mean the persons and entities for which insurance is being sought and their employees,
officers, partners and directors. Subsidiaries are also included if the entities have more than a 50% ownership
interest.
“We,” “us” and “our” mean the insurance company.
“Products” means products you design or manufacture to sell to others.
“Services” means activities you perform for others.
“Content” means data, digital code, images, masked works, scents, sounds, tastes, text or textures.
• In completing this application, you are not obligated to buy, and we are not obligated to sell, insurance.
• Incorrect, incomplete, false or misleading answers to any of the questions on this application may result in a retracted
offer of coverage or a declaration that the policy is null and void. Attach additional sheets if there is not enough room
in the application for an answer. If a question does not apply to you, respond “N/A” or “not applicable.” If you do not
answer a question, your answer will be deemed “not applicable.” You must answer all of the questions and
subparts of the TELL ALL Section of this application.
•
Any proposal of coverage that we make will have additional terms and conditions. Carefully review the proposal before
making a decision to purchase. As always, please contact your agent or broker if you have any questions.
THIS APPLICATION IS FOR A CLAIMS FIRST MADE AND REPORTED IN WRITING POLICY. CLAIM EXPENSE IS
WITHIN THE LIMITS. Refer to the policy for actual coverage details. Here’s an overview:
If issued, the policy will only apply to claims when
1 the glitch takes place on or after the retroactive date stated in the policy and before the end of the policy period and
2 the claim is first made against an insured person or entity and reported in writing to us during the time period specified
in the policy and in compliance with reporting requirements. An extended reporting period may also be available.
Covered claim expenses and damages must be paid by you up to the self-insured retention amount; these payments do
not reduce the limits of liability. Covered claim expenses and damages above the retention amount are payable under the
policy; they reduce and may exhaust the limits of liability.
BASICS
ALERT: To be eligible for this coverage, you must manufacture and design the majority of the products you sell. You
may want to ask your agent or broker to confirm eligibility prior to completing this application.
1. Applicant (fill in the name as it should appear on the policy, if written)
2. Street address
city, state, zip
Mailing address
city, state, zip Phone Number
3. Type of entity
Public Private
4. Entity structure
Sole proprietorship Corporation LLC Joint Venture Other
5. In business since (m/d/yyyy)
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 2 of 11
6. Have you purchased, merged or consolidated with any companies in the last three years?
Yes No. If yes, did purchase include (check all that apply) Assets Liabilities
7. Do you have any subsidiaries?
Yes No. If yes, please provide the names of all subsidiaries (attach a separate
list, if necessary)
8. Your staff
# of principals, partners, directors and officers
#of engineers and technicians
# of sales and marketing personnel
# of clerical/support personnel
# of independent contractors performing services on your behalf
# of website staff
# of other
TOTAL
9. Please list your website home page addresses (include all URLs registered in your name). If any of these website(s)
have a password protected members only/private area, also provide temporary passwords and log in ID.
Address Password/Log in ID
Address Password/Log in ID
Address Password/Log in ID
10. Does your website(s) contain a complete, accurate and up-to-date description of your products and services?
Yes No
11. Please list all association memberships related to your products and/or your services
12. SIC code(s) NAIC code(s)
VITALS
Fiscal
Year
Total Revenues,
including Your
Website Generated
Revenues
Your Website(s)
Generated
Revenues
only
Number
of Units
Manufactured
Average Price of
Products/Services
Next
U.S. $
Foreign $
TOTAL $
U.S. $
Foreign $
TOTAL $
$
Current
U.S. $
Foreign $
TOTAL $
U.S. $
Foreign $
TOTAL $
$
1. Do you do business outside the U.S.? Yes No. If yes, a) list all foreign countries in which you do business
and b) are you compliant with distance selling regulations and laws in foreign jurisdictions? Yes No
2. Indicate the % of your total current revenue from the following:
% products you design and manufacture
% products you sell or distribute for others
% fees for services you provide
% referral or affiliate program fees
% website ads for others
% licensing fees/royalties
% other
100% TOTAL
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 3 of 11
3. Do you accept credit/debit cards or other payment vehicles for transactions online?
Yes No. If yes, what fraud
prevention procedures do you employ? (check all that apply)
Address Verification Service (AVS) Verified by
Visa or MasterCard’s PCI/CISP
Verified by other Never accept orders from users using free e-mail
service Statement on your website regarding your intentions to prosecute fraudulent orders Secure third party
processor
Extra verification of large orders by phone call/written verification Other (describe)
YOUR WEBSITE(S)
1. Describe your website(s) (check all that apply)
Presence: just info about what you do
Content Aggregation: content from different sources
Interactive: visitors can interact with site
E-commerce: buying/selling of products and/or services
2. Do you plan to update your website(s) in the next year? Yes No. If yes, does this update include
New service info
Content from others
User interactivity (describe)
e-Commerce capabilities (describe)
User account access (describe)
Other (describe)
MANUFACTURING SERVICES FOR OTHERS
1. Please list the types of products you manufacture and services performed for others and the % of projected next
year revenues applicable to that product and/or service type, column sum must total 100%.
Description of Type of Product and/or Service % of projected next year revenues
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
TOTAL 100%
2. Do you manufacture or are any of your products and/or services used in the development of or incorporated into
the following? (check all that apply)
firearms, weapons, explosives or ammunition Yes No. If yes, indicate the percentage of projected next year
revenues %
toys or games Yes No. If yes, indicate the percentage of projected next year revenues %
tobacco Yes No. If yes, indicate the percentage of projected next year revenues %
drugs, pharmaceuticals, botanical, or biological products? Yes No. If yes, indicate the percentage of
projected next year revenues %
medical, dental or laboratory products Yes No. If yes, indicate the percentage of projected next year
revenues %
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 4 of 11
motor vehicles, trains, watercrafts or aircrafts? Yes No. If yes, indicate the percentage of projected next year
revenues %
chemicals, cleaning products, adhesives, or pesticides Yes No. If yes, indicate the percentage of projected
next year revenues %
alcohol Yes No. If yes, indicate the percentage of projected next year revenues %
food or beverages Yes No. If yes, indicate the percentage of projected next year revenues %
textiles, fabrics or apparel Yes No. If yes, indicate the percentage of projected next year revenues %
cosmetics or perfumes Yes No. If yes, indicate the percentage of projected next year revenues %
building or construction materials Yes No. If yes, indicate the percentage of projected next year revenues
%
3. For revenues that you will generate in your current fiscal year, what percentage of your products and/or services
are in the following Years in Market?
% Zero to One
% Over One year but less than Two
% Over Two years but less than Five
% Five years or longer
4. Are you developing any new products and/or services?
Yes No. If yes, please fill in the chart below
Product and/or Service
Projected Release
Date
*Projected Annual
Revenues
Projected Agreement
Value/Charge for Product
and/or Service
$ $
$ $
*If the product and/or service is to be released in the current or next fiscal year, did you include revenues in the VITALS
chart?
Yes No
5. Have you discontinued any of your products and/or services in the last three years?
Yes No. If yes, are any
of these products and/or services still in use by your customers?
Yes No. Do you plan to discontinue any of
your products and/or services in the next year?
Yes No
6. Indicate how far in advance you notify customers prior to discontinuance of a product and/or service
PRIVACY
1. Do you have a privacy policy? Yes No. If yes, a) has it been reviewed by an attorney? Yes No and b) is
the privacy policy posted on your website?
Yes No
2. Which of the following does your privacy policy contain? (check all that apply)
Explanation of type of info collected
Description of how info is collected
Disclosure of use of info collected
Access to and the ability for user to change or update info
Description of safeguards and security measures used to protect info
3 Do you provide opt-in or opt-out options in the following areas? (check all that apply)
Receipt by users of content from you or others Opt-in Opt-out
Collection of user information Opt-in Opt-out
Sharing of user info Opt-in Opt-out
4. Do you require users to actively agree to or acknowledge your privacy policy before they provide information?
Yes No
5. Is the point of information collection secure?
Yes No
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 5 of 11
6. Is personally identifiable and/or confidential information a) transmitted in encrypted form? Yes No and b) stored
in encrypted form?
Yes No
7. Do you sell or share personal and/or confidential information gathered from customers or others (this includes info
gathered from your website or by other means)?
Yes No. If yes, do you notify and obtain the consent of these
customers or others prior to dissemination?
Yes No
8. Do your operations require you to care for the confidential or personal info of others?
Yes No. If yes, indicate
which of the following kinds of info are cared for (check all that apply).
Medical Financial Inventory
Intellectual Property Customer Data Legal Work History/Resume Criminal Records
Other
CONTENT
1. Does your website contain a chatroom, bulletin board or any other type of interactive exchange which can be viewed
by others?
Yes No. If yes, does your website have disclaimers and guidelines regarding the use of and
content disseminated on the interactive exchange?
Yes No. Are users required to acknowledge disclaimers
and guidelines prior to participation?
Yes No. Who manages your interactive exchange? You
Subcontractor. Do you make the subcontractor contractually responsible for liabilities arising out of the interactive
exchange?
Yes No. Do you or your subcontractor exercise editorial control over your interactive exchange?
Yes No. If yes, when? Prior to Posting After Posting
2. In your advertising and marketing material, including all of your websites, do you a) compare yourself to your
competition?
Yes No, b) compare your products and/or services to your competitors’ products and/or
services?
Yes No, c) claim that you or your products and/or services are superior to your competition?
Yes No, and/or d) make guarantees or warranties? Yes No
3. What type of content is available on your website(s)? (check all that apply)
Entertainment/Games Law/Legal Advertising/Product Comparisons
Cultural (art/music) Insurance Contests/Surveys/Lotteries/Sweepstakes
Financial Software for downloading Instructional/How-to
Medical/Health Travel Database (include subject)
News Religious Your product and/or service information
Sports Commentary/Editorial Adult
Children’s Interest Other
4. Which of the following are included in your intellectual property and/or business methods clearance procedures?
(check all that apply)
The acquisition of all the necessary rights, licenses, releases and consents applicable to content and products
and/or services created or provided by you or by third parties
Legal review of the items checked below performed prior to release, use or dissemination regardless of the medium
content technology used products and/or services packaging business methods websites
advertising and marketing material
Legal review performed with respect to laws in jurisdictions outside of the U.S.
New hire and independent contractor agreements which include signed statements to the effect that they will not
disseminate or use a previous employer’s or client’s trade secrets and other intellectual property
The contractual acquisition of all rights (including electronic rights) to work done for you by third parties, including
hold harmless and indemnification clauses, which inure to your benefit pertaining to that work
Legal review of all updates or changes to the content, business methods and functionality of your website prior to
dissemination or implementation
Permission of sites you link to or frame
Legal review of sites you link to or frame
Legal review of all Referral and Affiliate Program agreements
Disclaimers on your website pertaining to content made available or disseminated
Trademark and/or servicemark searches and clearances for all your domain names product and/or service
names, designs or logos
content searches and clearances performed by your legal counsel professional search company
computerized database search
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 6 of 11
Permission to use and legal review of the trademarks and/or servicemarks of others
Legal review of all Licensing and/or Cross-Licensing Agreements
5. Do you have an established policy and process in place to address complaints of inaccurate, defamatory, infringing or
problematic content on your website(s), or other content you have designed or have responsibility for?
Yes No. If yes, what is your response timeframe? less than one day, 1-7 Days or more than a week
6. Do you have any corporate blogs, video logs, podcasts or webcasts?
Yes No. If yes, please provide the URL(s)
for all of them that are located on your corporate website(s):
and the URL(s) for all of them that are hosted for you by other websites, including social networking sites:
SECURITY
1. Please check all items from the following list that are currently being utilized in your security system and/or plan
Security firewall Protocols meeting x.509 standards
Routers Secure remote dialup or access
Proxy servers Computerized intrusion detection
Secure remote maintenance Mainframe data protocols
Firewall tunneling Automated security scanner
Encryption devices High-speed internet connections
Active content filtering Wireless security meets WPA standards Other
Password protection Access restrictions
Anti-virus scanning Load balancers
Hot site Penetration testing
ISO: compliant Periodic security audits from third parties
Identification, authentication and integrity protocols
Continuous monitoring of security alerts from organizations like CERT Other
Continuous implementation of vendor security patches
Procedures to address any suspected intrusion and/or respond to security alerts
Transmission of the data or content of others is encrypted
Storage of the data or content of others is encrypted
Other standard(s) and/or certification(s)
Reassessment of security vulnerabilities when you make any system changes, software upgrades, changes to
website or website functionality etc.
2. Do you have established systems and physical security policies and procedures?
Yes No. If yes, how often are
they updated?
continuously quarterly semi-annually annually. Are employees immediately notified of
changes and/or updates?
Yes No
3. Do you have established employee guidelines that address systems and Internet usage?
Yes No
4. Which of the following can access your systems via the Internet?
employees customers vendors
business partners
5. Do you have a Systems/Physical Security Manager?
Yes No
6. Is your disaster recovery program
formalized? tested?
7. How frequently do you back-up data residing on your system?
daily every 72 hours weekly other
8. Do you ever warrant or guarantee that your product and/or service or website has no security vulnerabilities or that
your product and/or service will prevent security breaches or the introduction of malicious code into the systems of
others?
Yes No
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 7 of 11
9. Have you experienced or has your system or website been used in any type of security incident or attack (e.g.
viruses, denial of service attacks, etc.)?
Yes No. If yes, please indicate which of the following happened. (check
all that apply)
security breach denial of service attack transmission of malicious code (ex: virus) identity
theft
disclosure of private information credit/debit card fraud repudiation of access other security incident
For each item checked above, please describe the incident or attack, impact to you, customers or others and what
measures you have to taken to prevent a similar event
ERRORS & OMISSIONS
1. Which of the following do Your quality control procedures include? (check all that apply)
Pre-release/pre-dissemination Alpha testing Formal customer acceptance procedures Beta testing
Vendor certification process Statistical process control Formalized quality control program Prototype
development
Products and/or services developed to industry standards: UL/CSA ISO 9000 or later series
CE Mark / ANSI Other
2. Do you include all necessary and required product labels, instructions and warnings with all of your products?
Yes No. Are the labels, instructions and warnings reviewed and approved by legal prior to inclusion?
Yes No
3. If your product and/or service were to fail, how many customers would be affected?
1-10 10-100 over 100
4. Indicate the acceptable downtime for your product and/or service according to your typical customers’ needs
None Less than one day Less than two days More than two days
5. What percentage of your products and/or services, upon delivery to your customers, are returned or require fixes?
%
6. Have you ever had to recall your products?
Yes No. If yes, please explain
7. Do you warrant or guarantee any standards of performance for your products and/or services (e.g. delivery and/or
completion timeframes, durability, quality?
Yes No. If yes, specify which standards
8. Do you subcontract out any part of your manufacturing operation? (Subcontractors include all contractors,
distributors, vendors, strategic partners and/or affiliates, etc. involved in the research, development, distribution, sale
of your products and/or services or management of your websites)
Yes No. If yes, indicate a) the percentage
of your current revenues attributable to the work of subcontractors % and b) your reasons for the use of
subcontractors (check all that apply) as a regular supplement to staff as staff for a particular project for
expertise that you do not have in-house
distribution other (please explain)
Do you make customers aware that subcontractors are being used? Yes No. Are the subcontractors identified
as such to customers?
Yes No. Describe what controls you have in place to ensure quality work from
subcontractors
9. Do your risk management procedures include the following? (check all that apply)
Business documents (customer orders, agreements, etc.) retained for months years unlimited
Maintenance of error/problem/downtime log for life of product and/or service
Customer complaint resolution plan
Customer notification plan of your discontinuance of a product and/or service or support
Customer or product support including E-mail Website Customer site visitation Fax In-house
repairs
Toll-free numbers Availability: M-F 24/7
Formal plan to address any flaws, defects, bugs, anomalies, problems, etc. discovered in your products and/or
services or website including
customer notification. Method of notification
Timeframe from discovery to notify all customers less than one day 1-7days 1-4weeks over 1 month
Formal service recall plan
10. Do you use a standard agreement with customers specifying the products and/or services you will provide?
Yes
No. If yes, indicate type executable contract shrinkwrap clickwrap/Terms of Service(TOS) engagement
letter
purchase order other
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 8 of 11
11. Indicate the percentage of your customers subject to your standard agreements %
12. Please indicate the following:
Typical Customer Agreement Largest Customer Agreement
Size $ Size $
Duration weeks months years Duration weeks months years
% of agreements modified or changed from your
standard agreement %
Type your standard agreement your standard
agreement with modifications
customer agreement
13. Are all customer agreements reviewed and approved by legal prior to execution?
Yes No
14. Are all changes and/or modifications to customer agreements and subcontractor/vendor agreements reviewed and
approved by legal prior to execution?
Yes No
15. Are all change orders and/or modifications in writing and approved by your legal counsel and signed off on by
customer prior to implementation?
Yes No
16. If your website allows e-commerce, do you require customers to read and accept your agreement before enacting a
transaction?
Yes No
17. In the chart below, check each of the following clauses that are built into your standard customer agreement and/or
your largest customer agreement and who the clause benefits
Clause
Standard Customer Agreement
Clause benefits
Largest Customer Agreement Clause
benefits
You Customer Mutually
Beneficial
N/A You Customer Mutually
Beneficial
N/A
Arbitration Clause
Choice of Law or Jurisdiction
Force Majeure
Guarantees/Warranties
Limitation of Liabilities
Limitation of Consequential
Damages
Hold Harmless/Indemnification
Schedule of Deliverables
Disclaimers
CURRENT INSURANCE
Do you carry Errors & Omissions/Professional Liability? Yes No
If no, explain If yes, please provide the following information Limit $ SIR/Deductible $
Premium $ Expiration Date Type of Form: Claims Made or Occurrence
Retroactive Date: Insurance Company
Do you carry General Liability?
Yes No
If no, explain If yes, does your coverage include? (check all that apply)
Personal Injury
Advertising Injury Products Liability. If yes, please also provide the following information
Limit $ SIR/Deductible $ Premium $ Expiration Date Type of Form:
Claims Made or
Occurrence Retroactive Date: Insurance Company
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 9 of 11
What is your desired Limit of Liability? (check all options that interest you) $500,000 $1,000,000
$2,000,000 $5,000,000 Other $ What is your desired Retention? (check all options that interest you)
$2,500 $5,000 $10,000 Other $
DO NOT ANSWER THE FOLLOWING QUESTION IF YOU ARE DOMICILED IN MISSOURI
1. Has your errors and omissions/professional liability coverage ever been declined, canceled or non-renewed?
Yes
No. If yes, please describe why
TELL ALL
you must answer all of the questions and subparts in this section
If you respond yes to questions 1–3 below, you must provide us with the following info
• a full description of the circumstances and details including any damages alleged;
• purchase or agreement (i.e. contract) price involved;
• the current status of the situation including what you have done and what you are now doing to address the
situation; and
• what you are doing to prevent further incidents or situations.
1. In the last three years, have any of your customers a) made allegations or complained about the performance or non-
performance of your product and/or service?
Yes No, b) refused to pay you or stopped paying you because
of a problem with your product and/or service?
Yes No, c) requested a refund of their payment because of a
problem with your product and/or service?
Yes No and/or d) complained that your product and/or service
was delayed or late?
Yes No
2. Are you aware of any actual or alleged fact, circumstance, situation, error or omission, or issues with your website,
content, product or service (including but not limited to, product, intellectual property, privacy and security issues)
which may reasonably be expected to result in a claim being made against any of you?
Yes No
3. Have any of you or any of your predecessors in business, affiliates or any of their past or present partners, owners,
officers, sales persons or employees been investigated and/or cited by any regulatory agency arising out of their
activities?
Yes No
If you respond yes to question 4 below, you must provide us with the following information about each and every
claim, suit or proceeding
• a full description including damages alleged;
• current status;
• loss runs, if applicable; and
• amounts of reserves, legal expenses paid to date, settlements or judgments
4. Have any claims, suits or proceedings relating to your products or services been brought during the past three years
against any of you or any of your predecessors in business, affiliates or against any of your or their past or present
partners, owners, officers, sales persons or employees?
Yes No
REPRESENTATIONS
This application must be signed by an authorized partner, officer or other principal of the primary entity seeking
coverage or by the proprietor of a proprietorship. By signing this application, you represent and agree to items 1
through 7 below:
1. You are acting on behalf of all persons and entities for which you are seeking insurance;
2. The statements and answers in the application and all attachments to it are accurate and complete.
Additional information provided in response to subsequent questions and requests will also be accurate and
complete;
3. Statements and information that you provide that are attached to or that supplement this application are
deemed to be incorporated into the application, and the application will be deemed to be incorporated into
and a part of any policy that is issued;
4. The statements, answers and additional information are representations by you; they are a material
inducement to us to provide insurance or a proposal for insurance; and you intend for us to rely upon them;
5. Any policy that we issue will be issued in reliance upon those representations;
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 10 of 11
6. You will report to us immediately, in writing, all changes in your business or circumstances that would result
in a different statement or answer or different information than the ones you have previously provided to us
when the change becomes known to you between the date of this application and the effective date of the
policy, if a policy is issued. We reserve the right to modify or withdraw any proposal for insurance that we
offer when we receive information about such changes;
7. If the application, including attachments and supplements, contains inaccurate, false or incomplete
information or if you fail to provide notice of changes as required, we may declare any policy that has been
bound or issued to be null and void, and we will not provide any coverage.
THE INSURANCE COVERAGE YOU ARE APPLYING FOR DOES NOT COVER CLAIMS
ARISING FROM OR RELATING TO BODILY INJURY OR PROPERTY DAMAGE.
STOP! BEFORE YOU SIGN THIS APPLICATION, READ THE APPLICABLE FRAUD WARNING ON THE FOLLOWING
PAGE
_____________________________________________ Date _______________________
Signature of AUTHORIZED SIGNATORY
______________________________________________
Printed Name of AUTHORIZED SIGNATORY Title________________________
Producer/Broker Name and License Number___________________________________________________
EUC0410P010 © 2003-2010, Euclid Managers, LLC Page 11 of 11
FRAUD WARNINGS
Alabama, Alaska, Arizona, Arkansas, California,
Connecticut, Delaware, Georgia, Idaho, Illinois, Indiana,
Iowa, Kansas, Massachusetts, Michigan, Minnesota,
Mississippi, Missouri, Montana, Nebraska, Nevada, New
Hampshire, North Carolina, North Dakota, Oregon,
Rhode Island, South Carolina, South Dakota, Texas,
Utah, Vermont, Wisconsin, Wyoming
NOTICE: In some states, 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, for the
purpose of misleading, conceals information concerning
any fact material thereto, may commit a fraudulent
insurance act which is a crime and subjects such person to
criminal and civil penalties in many states.
Colorado
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
claiming with regard to a settlement or award payable for
insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory
Agencies.
District of Columbia
WARNING: 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 fines. In addition, an insurer may
deny insurance benefits if false information materially
related to a claim was provided by the applicant.
Florida
Any person who knowingly and with intent to injure, defraud
or deceive any insurance company files a statement of
claim containing any false, incomplete, or misleading
information is guilty of a felony of the third degree.
Hawaii
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.
Kentucky
Any person who knowingly and with intent to defraud any
insurance company or other 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.
Louisiana, West Virginia
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.
Maine, Tennessee, Virginia, Washington
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, and denial of insurance benefits.
Maryland
Any person who knowingly OR willfully presents a false or
fraudulent claim for payment of a loss or benefit, or who
knowingly OR willfully presents false information in an
application for insurance, is guilty of a crime and may be
subject to fines and confinement in prison.
New Jersey
Any person who includes any false or misleading
information on an application for an insurance policy is
subject to criminal and civil penalties.
New Mexico
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 civil fines and criminal
penalties.
Ohio
Any person who, with intent to defraud or knowing 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.
Oklahoma
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.
Pennsylvania
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..
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Completed 8 January 2021

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