Page 5 of 5 01/01/18 ed.
PRODUCER'S SIGNATURE DATE
APPLICANT'S SIGNATURE DATE
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 and subjects that person to
criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which
may be a crime and may subject the personal to penalties). (In New York, the civil penalty is not to exceed five
thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ,
CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA & WY).
Applicable in AL, AR, AZ, DC, LA, MD, NM, RI & WV: Any person who knowingly (or willfully in MD) presents a false
or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information
in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
Applicable in Colorado: 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 or 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 Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of
a felony (In FL, a person is guilty of a felony of the third degree).
Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or
prepares with knowledge or 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 personal or commercial insurance, or a claim for payment or 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.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE
INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS
THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
Applicable in Maine, Tennessee, Virginia 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 may include
imprisonment, fines or denial of insurance benefits.
Atlantic Casualty Garage Application
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