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EMPLOYMENTPRACTICESLIABILITYAPPLICATION
1. Legalnameofthebusinesswhoistheprimaryapplicantandwillbethefirstnamedinsuredlistedonthepolicy:

2. Pleaselistallotherbusiness/dbanamesforwhichyouareseekingcoverageunderthispolicy:

3. Corporation  Individual Partnership Municipality ForProfit JointVenture
Other:
4. Pleaselistanynamesofotherentitiesthatyouownormanageorthatyoudobusinessunder(suchentitiesarenot
requestingcoverageunderthispolicy):

5. Primarylocationaddress:
6. Countyofprimarylocation:Datebusinessoriginallyestablished:
7. Totalnumberofbranches? Listalladdressesforadditionalbranches:

8. Whatisyourwebsiteaddress?www.
9. Whatisyourphonenumber?
10. Hasthenameorownershipoftheentitychangedorhasanyotherbusinessbeenpurchased, Yes No
mergedorconsolidatedwiththeentitywithinthelast5years?
11. Doesanyentityownorcontrolyourbusinessordoesyourbusinessownorcontrolanyentity? Yes
No
12. Duringthepastfiveyears,hasyournamebeenchangedorhasanyotherbusinesspurchased, Yes
No
mergedorconsolidatedwithyou?
Forquestions911,pleasefullyexplainany“yes”response,includingthenames,dates,andrevenueimpactinvolved:


13. Pleaselistanyassociationsofwhichyouareamember:

1. PleasedescribethenatureoftheApplicant’sbusiness(typeofproductorservicesprovided):

2. NumberofEmployees:FullTime:PartTime:
3. SalaryRangesNumberoffull Numberofpart
(includingbonuses,dividendsandcommissions) timeemployees timeemployees
$50,000orless:
$50,001to$100,000:
$100,001andover:
 TOTAL:

GENERALINFORMATION
EMPLOYEES(includingSubsidiaryemployeeinformationonaseparatesheet)
KinsaleInsuranceCompany
P.O.Box17008
Richmond,VA23226
(804)2891300
www.kinsaleins.com
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4. Ifyouhavemultiplelocations,pleaselistemployeesbystate:
S
tate:
S
tate:
S
tate:
S
tate:
S
tate:
FullTime 
PartTime 
5. DoestheApplicantuseseasonalortemporaryemployees? Yes
No
Ifso,whenandhowmany?
Aretheseemployeesincludedin#4above? Yes No
6. DoestheApplicantuseleasedworkers? Yes
No
IfYes,howmanyhavebeenretainedbytheApplicantinthepast12months?
Aretheseemployeesincludedin#4above? Yes No
7. DoestheApplicantuseindependentcontractors? Yes
No
IfYes,howmanyworksolelyfortheApplicant?
8. Howmanyemployeesarecoveredbycollectivebargainingorotherunionagreements?
9. Inthepast12months,howmanyofficershaveleftyouremploy?
Oftheabove,howmanywereterminated?
10. Inthepast12months,howmanyotheremployeeshaveleftyouremploy?
Oftheabove,howmanywereterminated?
1. Pleaseanswerthefollowingfour(4)questionsfortheApplicantslistedin#1and#2oftheGeneralInformationSection,
includingitssubsidiaries,forthemostrecentfiscalyearend:
a. WhataretheApplicant’stotalassets?
b. WhataretheApplicant’stotalgrossrevenues?
c. DoestheApplicantcurrentlyhave: NetIncome orNetLoss Amount$
d. DoestheApplicantcurrentlyhave:PositiveCashflow orNegativeCashflow Amount$
2. Hasanauditorintheprevioustwo(2)fiscalyearsrecommendeda“goingconcern”opinion Yes
No
ofthefinancialinformationfortheApplicant?(IfYes,pleaseprovidedetailsonaseparatesheet.)
3. Areyou: PubliclyHeld?
IfYes,pleaseprovidestocksymbol
PrivatelyHeld?
NonProfit?
Other?
Pleaseexplain.
1. Inthepasttwelve(12)months,hasyourtotalnumberofemployeesdecreasedbymore Yes
No
thantenpercent(10)orfive(5)employees,whicheverisgreater,throughanyreduction
inforce,systematiclayoff,closureofanydivision,officeorfacilitythatyouownoroperate
orforanyotherreason?(IfYes,pleasecompletetheReductionInForcesupplement.)
FINANCIALANDOPERATINGINFORMATION
EMPLOYMENTPRACTICES
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2. Inthenexttwelve(12)months,doyouanticipatethetotalnumberofyouremployees Yes No
todecreasebymorethantenpercent(10%)orfive(5)employees,whicheverisgreater,
throughanyreductioninforce,systematiclayoff,closureofanydivision,officeorfacility
thatyouownoroperateorforanyotherreason?(IfYes,pleasecompletetheReduction
InForcesupplement.)
3. Ifduringthenext12months,circumstancesofwhichareyoucurrentlyunawaremakeit Yes No
necessaryforyoutodecreasethenumberofyouremployeesbytenpercent(10%)orfive(5)
employees,whicheverisgreat,throughtheimplementationofanyreductioninforce,
systematiclayoff,closureofanydivision,officeorfacilitythatyouownoroperateorforany
otherreason(withany
suchreduction,layofforclosurenotknown,anticipatedorplannedby
youasofthedateofthisApplication),doyouagreethatyouwillconsultwith,andadoptthe
adviceof,alawyerwhospecializesinlaborandemploymentlaw(mayincludeinhouse
counsel,butonlyifthat
counselifqualifiedandexperiencedinthepracticeoflaborand
employmentlaw)asrespectstheimplementationofsuchreduction,layofforclosure?
(IfNo,pleaseexplainonaseparatesheet.)
4. DoestheApplicantanticipateanymerger,acquisition,oradditionofanyoperationsthat Yes
No
wouldcompriseatwentyfivepercent(25%)orten(10)employees,whicheverisgreater,
increaseoverthecurrentnumberofemployees?(IfYes,pleaseprovidefulldetailsona
separatesheet.)
5. HasanyinsurerevercancelledornonrenewedtheApplicantoritspredecessorforthis Yes
No
typeofcoverage?(IfYes,pleaseprovidedetailsonaseparatesheet.)
1. DoestheApplicanthavewrittenemploymentagreementswithallofficers? Yes
No
2. HavetheApplicant’smanagersand/orsupervisorsattendedtrainingandeducationprograms/ Yes
No
seminarsonsexualharassmentandothertypesofdiscriminationwithinthelast12months?
IfYes,whohasattended?
IfYes,whoconductsthesessions?
3. DoestheApplicanthaveitsemploymentpolicies/proceduresreviewedbylabororemployment Yes No
counsel?
IfYes,identifythefirmanddateoflastreview:
4. DoestheApplicanthaveaHumanResourcesorPersonnelDepartment? Yes No
IfNo,whohandlesthisfunction?
5. DoestheApplicanthaveanemployeehandbook? Yes No
IfYes,doestheApplicantdistributeittoallemployees? Yes
No
IfYes,doallemployeessignupforitsreceipt? Yes
No
IfYes,doesitexpresslystatethatitisnotacontractandthatemploymentis“atwill”? Yes
No
6. DoestheApplicanthavewrittenproceduresforhandlingemployeecomplaintsofdiscrimination Yes
No
and/orsexualharassment?
7. DoestheApplicantrequireallterminationstobereviewedby:
Thepersoninchargeofhumanresources? Yes
No
Outsidecounsel? Yes
No
8. DoestheApplicantmaintainapersonnelfileforeachemployee? Yes
No
HUMANRESOURCES
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1. Estimatednumberofemployeeswithcustomer/clientcontact:
2. Pleasedescribethefrequencyandnatureofcustomer/clientinteractions.

3. HastheApplicantoritspredecessorseverreceivedacomplaint,formalorinformal,froma Yes
No
nonemployee,suchasacustomer,client,orprospectivecustomerorclientcomplainingabout
discriminationorharassmentbytheApplicantoranyemployeeoftheApplicant?
(IfYes,pleaseprovidedetailsonaseparatesheet.)
4. DoestheApplicantconductstafftrainingonclientandcustomerrelationsissuessuchas
 Yes No
avoidingdiscriminatorybehavior?
5. Arethereproceduresforreportinganddealingwithcomplaintsbycustomers/clients? Yes
No
6. IstheApplicantincompliancewithTitleIIIoftheAmericanswithDisabilitiesAct Yes
No
(buildingandpremisesrequirements)?
1. Afterinquirywitheachpersonasappropriate,inthelastfive(5)years,doesanyonehaveany Yes
No
otherMaterialFactstodisclose?(IfYes,pleaseprovidesuchMaterialFactsonaseparatesheet.)
AMaterialFactisonelikelytoinfluenceassessmentofthisrisk,thepremiumchargedorthetermsandconditions
imposedbyUnderwriters.Ifyouareinanydoubtastowhetherafact
wouldbeconsideredmaterial,youshould
discloseit.Alloftheinformationrequestedinthisproposalismaterial.
1. Provideyourfirm’srecentEmploymentPracticesLiabilityinsurancehistorybelow(includingcoverageaspartofaD&O
orotherinsurancepolicy):
InsuranceCompany
LimitsPerClaim/
Aggregate Deductible
PolicyPeriod
(Month/Day/Year)
Annual
Premium
CurrentYear
PreviousYear1
PreviousYear2
PreviousYear3
PreviousYear4
2. Ifyouarecurrentlyinsuredforemploymentpracticesliabilitycoverage,whatisyourpolicy’sretroactivedate?
(month/date/year)?____/_____/______Ifthereisnoretroactivedate,pleasecheckhere.
THIRDPARTYINFORMATION
OTHERMATERIALINFORMATION
INSURANCEANDLOSSHISTORY
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Ifrequestingprioractscoverageyouwillbeaskeduponbindingcoveragetoprovideacopyofyourcurrentinsurance
declarationpagedocumentingtheexpiringretroactivedateandlimits.Prioractscoveragemaynotbeavailableifthe
dateofyourcurrentretroactivecoverageisdifferentfromwhatwehavequoted
orifthereisanygapbetween
effectivedates.

3. Areyoubeingcanceledornonrenewedbyyourcurrentemploymentpracticesliabilitycarrier? Yes
No
IfYes,pleaseexplainwhy:
4. RequestedLimits:
$100,000/$300,000 $250,000/$250,000 $500,000/$500,000 $1,000,000/$1,000,000
Other$/$
RequestedDeductible(PerClaim):
$5,000$10,000 $25,000 Other
5. Afterinquirywitheachpersonasappropriate,inthelastfive(5)years,hasanywrongfultermination, Yes
No
discrimination,sexualharassmentoranyotherwrongfulemploymentpracticesliabilityclaim
orsuit,includingthirdpartyclaims,everbeenmadeagainsttheFirmoranypredecessorfirmor
anycurrentorformermemberoftheFirmorpredecessorfirm?
If“Yes,”howmany?PleasecompleteaseparateSupplementalClaim
Form
foreachclaimorsuitandincludeacurrentlyvaluedlossrunforeachclaim.
6. Afterinquirywitheachpersonasappropriate,doyou,oranyofyourpartners,officers, Yes
No
directors,oremployeesknowofanycircumstances,acts,errors,omissions,oranyallegations
orcontentionsofanyincidentthatcouldresultinanunemploymentrelatedclaim,including
thirdpartyclaims?
If“Yes,”howmany?If“Yes,”pleasecompleteaseparateSupplemental
ClaimFormforeachpotentialclaimandprovideasmuchdetailaspossible.
7. OfthetotalnumberofEEOC/stateagencychargesfiledagainstanyApplicantoverthelastfiveyears,indicatethe
numberofprimaryallegationsasfollows:
1) LocationNo. 2) Racial
Discrimination
3) Age
Discrimination
4) Religious
Discrimination
5) OtherEthic
Discrimination
6) EqualPay
ActViolation
7) Other
Gender
Discrimination
8) Violationof
Am.With
Disabl.Act




8. Withrespecttolitigatedcases(includingwrongfulterminationsuitsunderstatelawotherthanantidiscriminationlaw)
andEEOC/stateagencychargesoverthelastfiveyearsforwhichanysettlementwasormaybepaid,pleaseprovidethe
followinginformation,whichmustbecurrentlyvalued:
Date
Occurrence
Claimant Allegation DamagesPaid DamagesReserved LegalExpenses
Paid
LegalExpenses
Reserved


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FRAUDWARNING
NOTICETO 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,NORTHDAKOTA,OREGON,RHODEISLAND,SOUTHCAROLINA,SOUTHDAKOTA,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 orstatement of claim containing any materially false information, or, for the purpose of misleading, conceals
informationconcerninganyfactmaterialthereto,maycommitafraudulentinsuranceactwhich
isacrimeinmanystates.
NOTICETOCOLORADOAPPLICANTS:Itisunlawfultoknowinglyprovidefalse,incompleteormisleadingfactsorinformationtoaninsurancecompanyfor
thepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialofinsuranceandcivildamages.Any
insurancecompanyoragent ofaninsurancecompanywhoknowinglyprovidesfalse,incompleteormisleadingfactsorinformationtoa policyholderor
claimantforthepurposeofdefraudi ng orattemptingtodefraudthepolicyholderorclaimi ngwithregardtoasettlementorawardpayableforinsurance
proceedsshallbereported
totheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.
NOTICETODISTRICTOFCOLUMBIA APPLICANTS: WARNING:Itis a crime to provide falseor misleading informationtoaninsurerforthe 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
informationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.
NOTICETO FLORIDAAPPLICANTS:Anyperson whoknowinglyand withintentto injure,defraud ordeceiveanyinsurancecompany filesa statementof
claimcontaininganyfalse,incompleteor
misleadinginformationisguiltyofafelonyofthethirddegree.
NOTICETOHAWAIIAPPLICANTS:Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossor
benefitisacrimepunishablebyfinesorimprisonment,orboth.
NOTICETOKENTUCKY
APPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commitsafraudulentinsuranceact,whichisacrime.
NOTICE
TO LOUISIANA APPLICANTS:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.
NOTICETOMAINEAPPLICANTS:
Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurpose
ofdefraudingthecompany.Penaltiesmayincludeimprisonment,fines,ordenialofinsurancebenefits.
NOTICETONEWJERSEYAPPLICANTS:Anypersonwhoincludesanyfalseormisleading informationonanapplication
foraninsurancepolicyissubjectto
criminalandcivilpenalties.
NOTICE TO NEW MEXICO APPLICANTS:Any person who knowingly presents a false or fraudulentclaim for payment of a loss or benefit or knowingly
presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmay
besubjecttocivilfinesandcriminalpenalties.
NOTICETONEWYORKAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudaninsurancecompanyorotherpersonfilesanapplicationfor
insuranceorstatement ofclaimcontaining anymateriallyfalse information,or conceals,forthepurposeof misleading,information
concerninganyfact
materialthereto,commitsafraudulentinsuranceact,whichisacrimeandshallalsobesubjecttoacivilpenaltynottoexceed$5,000andthestatedvalue
oftheclaimforeachsuchviolation.
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
applicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.
NOTICETOOKLAHOMAAPPLICANTS:WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makesaany
claim
fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
NOTICE TO PENNSYLVANIA APPLICANTS:Any person who knowingly and with intent to defraud any insurance company, or other pe rson, files an
application for insurance or statement of a claim containing
any materially false information or conceals for the purpose of misleading, information
concerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectsthepersontocriminalandcivilpenalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the
purposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
NOTICETOVIRGINIAAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incompleteormisleading informationtoaninsurancecompanyforthepurpose
ofdefraudingthecompany.Penaltiesincludeimprisonment,
finesanddenialofinsurancebenefits.

Page7of10
TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthatthe
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omitanymaterialfacts.
TheApplicantagreesto
notifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffective
dateofanypolicyissuedpursuanttothisquestionnaireandtheApplicantunderstandsthatanyoutstandingquotationsmaybemodifiedorwithdrawn
baseduponsuchchangesatoursole
discretion.
Completion ofthisformdoesnotbindcoverage. Applicant’sacceptanceofthe company’squotationisrequired prior tobinding coverageandpolicy
issuance.
All written statements and materi als furnished to the company in conjunction with this application are hereby incorporated by reference into this
applicationandmadea
partofthisapplication.
Applicant: Title:
(MustbesignedbyaDirectorofHumanResourcesorother
Principal,Partner,orOfficeroftheFirm)
Applicant’sSignature: Date:
Agent/BrokerName: 
click to sign
signature
click to edit
Page8of10
EMPLOYMENT
PRACTICESLIABILITYCLAIMAPPLICATION
ThisformistobecompletedwhentheApplicanthasbeeninvolvedinanyclaimorisawareofanincidentwhich
maygiverisetoaclaim.COMPLETEONEFORMFOREACHCLAIMORINCIDENT.
Ifspaceisinsufficienttoansweranyquestionsfully,attacha
separatesheet.
Inlieuofattachingsuitpapers,pleaseprovideacompletenarrativedescriptionoftheallegationsinvolved
1. FullNameofApplicant:
2. FullNameofIndividual(s)orentityinvolvedintheclaim:
3. Additionaldefendants
4. FullNameofClaimant:
5. a. IstheClaimantstillyouremployee(orclientifaThirdPartyClaim)afterbringingtheclaim? Yes
No
b. Areotherwitnesses/involvedpartiesstillemployed? Yes
No
6. Dateofclaim:DatereportedtoInsuranceCompany:
7. Whatisthestatusoftheclaim? Closed/Settled
 Open/Pending Incident/Circumstance
8. IFCLOSED:
Totalpaidincludingdeductible(s)?Responsessuchas“unknown”or“unavailable”areinsufficient.
Defensecosts Loss/compensatorydamages
Paidbyyououtofpocket $ $
InsuranceCompany $ $

DateResolved:_____/_____/_____ Trial
 OutofCourt 

9. IFPENDING:
(a) Claimant’ssettlementdemand?$ _____Defendant’ssettlementoffer(ifany):$
(b) Insurer’sreserveamounts?Loss$Defense$
(c) Amountsalreadyspentdefendingtheclaim?Byyou?$Bytheinsurer?$
(d) Whatisyourbestestimateofthelikelysettlementamountforthismatter?$
(e) Whatisyourbestestimateofthedatewhenyouexpectthisclaimtoberesolved?
Note:Answering“unknown”or“unavailable”totheabovequestionsisaninsufficientresponse.
10. Theclaiminvolves/involvedthefollowinglawsorissues(pleasecheckallthatapply):
AffirmativeAction
FalseImprisonment Slander 
BodilyInjury GoodFaithandFairDealing ThirdParty/NonEmployeeClaim
(Ifso,pleaseexplain.)
________________________________
BreachofWrittenContract ImpliedContract WhistleBlowerRetaliation
APPLICANT’SINFORMATION
KinsaleInsuranceCompany
P.O.Box17008
Richmond,VA23226
(804)2891300
www.kinsaleins.com
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Discrimination
(Type:___________________________
________________________________
________________________________)
InvasionofPrivacy
WrongfulTermination
EmotionalDistress Libel/Defamation OtherIssues:____________________
_
_________________________________
_________________________________
_________________________________
_________________________________
EqualPayAct(EPA) Retaliation
FLSA(FairLaborStandards)
WageandHour
Retaliation(Type):______________
_
_______________________________
FMLA SexualHarassment
11. Name(s)ofInsurer(s)respondingtothisclaimorincident
PolicyNumber:
LimitsofLiability:Deductible:
12. Providenarrativedescriptionofsuit,claimorincident,includingtheallegationsinvolved,thepotentialsizeofinjury
andyourresponse:

13. Explainwhataction(s)havebeentakentopreventreoccurrenceofasimilarclaim: ______
_____
Ideclarethattheinformationsubmittedhereinistruetothebestofmyknowledgeandbecomesapartofmy
EmploymentPracticesLiabilityApplication.Iunderstandthatanincorrectorincompletestatementcouldvoid
myprotection.

SignatureofApplicant/Title/Date (MustbesignedbyaPrincipal,PartnerorOfficeroftheFirm)
FRAUDWARNING
NOTICETO 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,NORTHDAKOTA,OREGON,RHODEISLAND,SOUTHCAROLINA,SOUTHDAKOTA,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 orstatement of claim containing any materially false information, or, for the purpose of misleading, conceals
informationconcerninganyfactmaterialthereto,maycommitafraudulentinsuranceact
whichisacrimeinmanystates.
NOTICETOCOLORADOAPPLICANTS:Itisunlawfultoknowinglyprovidefalse,incompleteormisleadingfactsorinformationtoaninsurancecompanyfor
thepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialofinsuranceandcivildamages.
Any
insurancecompanyoragent ofaninsurancecompanywhoknowinglyprovidesfalse,incompleteormisleadingfactsorinformationtoa policyholderor
claimantforthepurposeofdefraudi ng orattemptingtodefraudthepolicyholderorclaimi ngwithregardtoasettlementorawardpayableforinsurance
proceedsshallbe
reportedtotheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.
NOTICETODISTRICTOFCOLUMBIA APPLICANTS: WARNING:Itis a crime to provide falseor misleading informationtoaninsurerforthe 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
informationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.
NOTICETO FLORIDAAPPLICANTS:Anyperson whoknowinglyand withintentto injure,defraud ordeceiveanyinsurancecompany filesa statementof
claimcontaininganyfalse,incomplete
ormisleadinginformationisguiltyofafelonyofthethirddegree.
NOTICETOHAWAIIAPPLICANTS:Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossor
benefitisacrimepunishablebyfinesorimprisonment,orboth.
NOTICE
TOKENTUCKYAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commitsafraudulentinsuranceact,whichisacrime.
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NOTICE TO LOUISIANA APPLICANTS:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.
NOTICETOMAINEAPPLICANTS
:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurpose
ofdefraudingthecompany.Penaltiesmayincludeimprisonment,fines,ordenialofinsurancebenefits.
NOTICETONEWJERSEYAPPLICANTS:Anypersonwhoincludesanyfalseormisleading informationonan
applicationforaninsurancepolicyissubjectto
criminalandcivilpenalties.
NOTICE TO NEW MEXICO APPLICANTS:Any person who knowingly presents a false or fraudulentclaim for payment of a loss or benefit or knowingly
presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeand
maybesubjecttocivilfinesandcriminalpenalties.
NOTICETONEWYORKAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudaninsurancecompanyorotherpersonfilesanapplicationfor
insuranceorstatement ofclaimcontaining anymateriallyfalse information,or conceals,forthepurposeof
misleading,informationconcerninganyfact
materialthereto,commitsafraudulentinsuranceact,whichisacrimeandshallalsobesubjecttoacivilpenaltynottoexceed$5,000andthestatedvalue
oftheclaimforeachsuchviolation.
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
applicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.
NOTICETOOKLAHOMAAPPLICANTS:WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makes
aanyclaim
fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
NOTICE TO PENNSYLVANIA APPLICANTS:Any person who knowingly and with intent to defraud any insurance company, or other pe rson, files an
application for insurance or statement of a
claim containing any materially false information or conceals for the purpose of misleading, information
concerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectsthepersontocriminalandcivilpenalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete
or misleading information to an insurance compan y for the
purposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
NOTICETOVIRGINIAAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incompleteormisleading informationtoaninsurancecompanyforthepurpose
ofdefraudingthecompany.
Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthatthe
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate
or
omitanymaterialfacts.
TheApplicantagreestonotifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffective
dateofanypolicyissuedpursuanttothisquestionnaireandtheApplicantunderstandsthatanyoutstandingquotationsmaybemodified
orwithdrawn
baseduponsuchchangesatoursolediscretion.
Completion ofthisformdoesnotbindcoverage. Applicant’sacceptanceofthe company’squotationisrequired prior tobinding coverageandpolicy
issuance.
All written statements and materi als furnished to the company in conjunction with this application are hereby incorporated
by reference into this
applicationandmadeapartofthisapplication.
Applicant:______________________________________ Title:
(MustbesignedbyaPrincipal,Partner,orOfficeroftheFirm)
Applicant’sSignature:_____________________________Date:
Agent/BrokerName: