CPS-APPs (11-06) Page 3 of 3
6. Previous carrier and loss information (last three years): Check if no losses last three years
Year Company Policy No. Premium
Date of
Loss
Losses
Paid/Reserved
Description of
Loss
Any other insurance with this company or being
submitted? (Please list name[s] and/or policy number[s]):
Any policy or coverage declined, canceled or non-
renewed during the prior three years? Why? (Not
applicable in Missouri)
This application does not bind YOU nor US to complete the insurance, but it is agreed that the information contained
herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING:
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.
FRAUD WARNING (APPLICABLE IN TENNESSEE AND 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 include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:
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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: Date:
(Must be signed by an owner, partner or executive officer)
PRODUCER’S SIGNATURE: Date:
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signature
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signature
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