Fillable Collections Law Supplement

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Collections Law Supplement

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  • 12 check-boxes
  • 19 other fields

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Page 1 of 3
COLLECTIONS LAW SUPPLEMENTAL APPLICATION
1. Please provide a breakdown of the firm’s collections practice:
Type of collection % of collections practice (to
total 100%)
Average amount collected by
firm per debtor
Consumer:
Commercial:
2. During the past 12 months, how many attorneys have handled collections work? How many
non-attorneys have handled collections work?
3. Does any member of the firm have an equity interest in an organization operating Yes No
as a collection agency?
If yes, please explain.
4. Does the firm have written procedures that all attorneys and staff are required Yes No
to follow to ensure compliance with the State and Federal Fair Debt Collection
Practices Act?
If No, please explain.
5. Does the firm require use of a script which has been reviewed for compliance Yes No
with the Federal Fair Debt Collection Practices Act and applicable state law
when collecting debts via phone?
If No, please explain.
6. Have all form letters and other correspondence been reviewed for compliance Yes No
with all federal and state statutes?
7. Does the firm call debtor’s cellular telephone numbers? Yes No
8. Does the firm document that the debtor has granted written permission to Yes No
call the cellular telephone in compliance with the Telephone Consumer
Protection Act?
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 3
9. Please explain how the firm stays current on state and federal statutes relative to its collections
practice.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS,
INDIANA, IOWA, KANSAS, MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA,
NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA,
TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS: 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 in many states.
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
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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: 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.
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 KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: 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 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 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 NEW MEXICO APPLICANTS: 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.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: 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.
Page 3 of 3
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes a any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a
felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other
person, files an application for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
NOTICE TO 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 include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The
Applicant warrants that the above statements and particulars together with any attached or appended documents are true and
complete and do not misrepresent, misstate or omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise
prior to the effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding
quotations may be modified or withdrawn based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding
coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by
reference into this application and made a part of this application.
Applicant:
______________________________________
(Must be signed by a Principal, Partner, or Officer of the Firm)
Title:
Applicant’s Signature:
_____________________________
Date:
Agent/Broker Name:
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Collections Law Supplement

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Completed 2 July 2020

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