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CPL10/15 – USLI
Oklahoma Fraud Statement: 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.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Kentucky, Pennsylvania AND Ohio Fraud Statement: 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.
Tennessee, Virginia and Washington Fraud Statement: 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 Statement (All Other States): 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.
STATE NOTICES
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the
misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard
assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not
have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application
for the policy or otherwise.
Florida Surplus Lines Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be
available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Punitive Damage Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida
and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed
punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy
provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to
“vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.
Maine Notice: The insurer is not permitted to withdraw any binder once issued, but a prospective notice of cancellation may be sent and coverage denied for
fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.
Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this
application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10
days’ notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
Ohio Representation Statement: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company
are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage
provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications
are incorporated into, and shall form part of, this policy. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL MISREPRESENTATION
OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND WITHOUT EFFECT OR PROVIDE THE
COMPANY THE RIGHT TO RESCIND IT.
Utah Punitive Damages Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or
exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside
the state of Utah, for which coverage is sought under the same policy.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name:____________________________________________________ License #: ________________________________________________
Agent’s signature:______________________________________________________ Main agency phone number: _________________________________
(Required in New Hampshire)
Agency mailing address: __________________________________________________________________________________________________________
City: _______________________________________________________________________ State:__________________ Zip: ______________________
The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the
requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this
Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring
prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer
immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium
charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with
the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be
deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is
agreed that this Application shall be the basis of the contract should a policy be issued and it will be attached and become a part of the Policy.
Applicant’s signature: ______________________________________________________________________ Title: ________________________________
President, Chairperson of the Board, Managing Member, or Executive Director
Date:_____________________________________________________
mportant Notice Regarding the Fair Credit Reporting Act:
I understand that as part of the underwriting procedure, a consumer report may be obtained in connection with the application for insurance
and subsequent amendments and renewals. Such reports may include information regarding my driving record. Information collected by the
Company or its authorized representatives may, in certain circumstances, be disclosed to third parties without my authorization. I have the right
to review my personal information in the Company files and can request correction of any inaccuracies.
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