Signature of Applicant (Insured)
Date
Applicable in AL, AR, DC, LA, MD, NM, RI and WV
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. *Applies to ME Only.
Applicable in CO
It is unlawful to knowingly provide false, incomplete, or misleading fact or information to an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may include imprisonment, fines and 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 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.
Applicable in FL and OK
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge of belief that it will be
presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application
for the issuance of, or the rating of an insurance policy for the person or commercial insurance, or claim for payment or the other benefit
pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information
concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act.
Applicable in KY, NY, OH and PA
Any person who knowingly and with intent to defraud any insurance company or the 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* (not to exceed
five thousand dollars and the stated value of the claim for each such violation)*. * Applies to NY Only.
Applicable in ME, TN, VA and WA
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. *Applies to ME Only.
Applicable in NJ
Any person who includes and false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing false
statement as any material fact maybe violating state law.
Applicable in PR
Any person who knowingly and with intention of defrauding presents false information in an insurance application, or presents, helps, or
causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than on claim for the same
damage or loss shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand
dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment of three (3) years, or both penalties.
Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5)years, if extenuating
circumstances are present, it may be reduced to a minimum of two (2) years.
NOTICE TO THE INSURED: Any person who knowingly and with intent to defraud any insurance company
or the 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. [NY: not to exceed five thousand dollars and the stated value of the claim for each such
violation] (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, and VA, Insurance benefits
may also be denied).
I understand that the insurance company is determining whether to provide a quotation for insurance
coverage will rely on the information contained in the application and all other information being
submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information
provided is complete, true and correct.
I also understand that no insurance will be in effect unless and until the insurance company or AON Edge
as its agent, provided a quotation offering to provide insurance coverage and the insurance company or
AON Edge as its agent, receives written notice that the terms and conditions contained in the insurance
quotation provided are accepted.
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