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Page 1 of 8
LAW ENFORCEMENT PROFESSIONAL LIABILITY APPLICATION
1. Legal name of the entity who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other entity/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
6. County of primary location: Date entity originally established:
7. Provide street addresses of all locations where law enforcement operations are headquartered or located, and any
auxiliary locations (other than the address shown in 5. above).
8. Current population of city, town, county or other political subdivision which Applicant provides services to:
9. Department Administrator or Contact Person (Name and Title):
10. Any seasonal increase in population? Yes No
If “Yes:
(a) Indicate percentage of increase and season: %
(b) Are there any borrowed officers during this season? Yes No
(c) If “Yes” to (b), are they trained on the Applicant’s policies and procedures? Yes No
(d) How many are borrowed?
11. Jurisdiction of Applicant: City/Town County State Other:
12. What is the largest city and its population, within a 25 mile radius of the Applicant’s main headquarters?
13. Indicate the name, type and size of significant facilities within the Applicant’s jurisdiction, (i.e., military institutions,
colleges, universities, resorts, convention centers, sport arenas, nuclear power plants, amusement parks):
14. What is your web-site address? www.
15. What is your phone number and e-mail address?
16. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
17. Does any entity own or control your entity or does your entity own or control any entity? Yes No
18. During the past five years, has your name been changed or has any other entity purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 11
19. Please list any associations of which you are a member:
I. PERSONNEL
POSITIONS TO BE INSURED (List personnel only once under primary classification.)
Class A employees (If none enter “none”. Provide number to be insured.)
1) Sheriff/Chief
2) Chief Deputy/Deputy Chief
3) Personnel with rank of Sergeant or higher
4) Full-time personnel with regular street/road duties and detectives & investigators
(Do not include #3.)
5) Jail administrators
6) Police dogs (Provide certificate of training for dog and handler.)
Total # Class A Employees:
Class B employees (Provide number to be insured.)
1) Full-time jailers/matrons (below rank of Sergeant)
1) a) Part-time, including dispatchers performing as jailers on a part-time basis
2) Civil process
3) Court Security staff
4) Part-time auxiliary/reserve officers armed or with arrest authority
5) Mounted police patrols (Horses)
Total # Class B Employees:
Class C employees (Provide number to be insured.)
1) School crossing guards (employed by law enforcement agency)
2) Animal control officers (employed by law enforcement agency)
3) Medical Personnel: EMPLOYED CONTRACTED PROF LIAB LIMITS ON CERT?
Jail Nurses
Doctors/Phys. Asst.
Coroners
Dentists or other
4) Unarmed part-time/auxiliary/reserve officers without arrest authority
5) Communication/dispatcher
Total # Class C Employees employee/contracted:
Class D employees (Provide number to be insured.)
1) Clerical personnel employed by law enforcement agency
2) Jail cooks
3) All personnel not covered above Please explain:
Total # Class D Employees:
TOTAL # of All Staff – Class A+B+C+D:
GENERAL INFORMATION
Page 3 of 11
1. Does the Applicant contract its law enforcement services to any other public or private entity? Yes No
If “Yes”, please attach a copy of the servicing contract(s).
(a) If “Yes”, indicate name and location of such other entity/ies:
(b) If “Yes”, are any additional personnel retained by the Applicant for such purposes listed Yes No
under Section VI.?
(c) If “No”, to (b), please explain:
2. Is the Applicant a party to any mutual aid, reciprocal, or regional task force agreements? Yes No
If “Yes”, please attach a copy of such agreement(s).
3. Does the Applicant require it be named as an “Additional Insured” when providing law Yes No
enforcement services to any other public or private entity pursuant to contract or for approved
special events (i.e., concerts, parades, races)?
4. Does the Applicant authorize moonlighting by its law enforcement officers? Yes No
(a) If “Yes”, indicated name and title of individual who authorizes:
(b) What percentage of the law enforcement staff moonlights, on average? %
(c) Is moonlighting authorized in gentlemen’s clubs, concert venues, bars, taverns, or other Yes No
establishments serving alcohol?
II. POLICIES AND PROCEDURES
1. Does the Applicant have a law enforcement policies and procedures manual? Yes No
If “Yes”:
(a) What is the original publication date?
(b) What is the date of last revision or update?
(c) Is the manual distributed to all personnel? Yes No
(d) Is the manual reviewed with personnel periodically as part of their formal training? Yes No
2. Does the Applicant have written policies and procedures relating to:
(a) AIDS Yes No Date of Last Update:
(b) Domestic Violence Yes No Date of Last Update:
(c) Handling of Intoxicated Individuals Yes No Date of Last Update:
(d) Use of Deadly Force Yes No Date of Last Update:
(e) Use of Non-Deadly Force Yes No Date of Last Update:
(f) Vehicle Hot Pursuit Yes No Date of Last Update:
Please attach a copy of all such policies and procedures.
3. Does the Applicant monitor compliance with its policies and procedures on a regular basis? Yes No
If “Yes”, describe how compliance is monitored.
If “No”, please explain.
4. Does the Applicant require “Use of Force” reports to be filed by its officers? Yes No
(a) If “Yes”, are they followed up on by Applicant? Yes No
(b) How many such “Use of Force” reports were filed in the past 24 month?
5. Please provide the number of officers equipped with recording devices: (If no officers are equipped with recording
devices, please enter “none”.
Audio Only
Video Only
Both Audio & Video
Body Cameras
Dashboard Camera
Page 4 of 11
1. What is the minimum education requirement for hiring an officer?
(a) High School Diploma/GED
(b) Some College
(c) College Graduate
(d) Other (explain):
2. Is psychological testing required before hiring any officer? Yes No
(a) If “Yes”, are results reviewed by a person trained in this field? Yes No
(b) Is officer interviewed by a psychologist or psychiatrist? Yes No
3. What background investigations are completed prior to hiring any officer?
4. If the Applicant has a lockdown facility, what training of correctional officer is required before assignment?
(a) Full-time jailers: Formal Academy? Yes No N/A # of Hours:
Other (explain):
(b) Part-time jailers: Formal Academy? Yes No N/A # of Hours:
Other (explain):
5. What law enforcement training is required of armed street officers?
Formal Academy? Yes No N/A # of Hours:
Other (explain):
6. Does the Applicant have a minimum in-service training update: Yes No
(a) If “Yes”, how often? Monthly Annually Bi-Annually
Other: # of hours:
7. Is formal training required before an officer is armed and assigned street duty? Yes No
(a) If “No”, verify that officer is either: Not Armed Is Armed, but is accompanied by a trained officer
8. Are officers trained an qualified before using:
(a) A Baton? Yes No Not Used
(b) Mace/Chemicals? Yes No Not Used
(c) Control Holds? Yes No Not Used
(d) Stun guns? Yes No Not Used
(e) Canine handling? Yes No Not Used
9. How often must an officer re-qualify with:
(a) Service Revolver?
(b) Personal Weapon?
(c) Other Weapon? (Please specify)
10. Does firearm training include firing range exercises at night of simulated night conditions? Yes No
11. What training do part-time or auxiliary officers armed with arrest authority received?
(a) Is training given before assignment? Yes No
(b) If “No”, verify that officer is either: Not Armed Is Armed, but is accompanied by a trained officer
EDUCATION AND TRAINING REQUIREMENTS OF OFFICERS
Page 5 of 11
(c) What type of assignments do auxiliary officers typically perform?
12. Are officers trained in emergency vehicle handling (i.e., “hot pursuit”)? Yes No
13. Has the Applicant received accreditation from the Commission on Accreditation for Law Yes No
Enforcement Agencies, Inc.?
1. Does the Applicant handle its own police dispatch? Yes No
(a) If “No”, who handles for the Applicant?
2. Does the Applicant dispatch for other public entities or police units? Yes No
(a) If “Yes”, how many other entities or units?
(b) What is the total population served?
3. Are incoming calls to dispatch recorded? Yes No
(a) If “Yes”, how long are recordings retained by the Applicant?
4. Are the following services provided by the Applicant?
(a) Emergency Medical Dispatch Yes No
(b) Fire Dispatch Yes No
(c) Police Dispatch Yes No
5. What training do the dispatchers receive (please describe for each category of services provided)?
IF NO LOCK-UP FACILITY, PLEASE CHECK BOX AND GO TO NEXT SECTION. NO LOCK-UP FACILITY
1. Does the Applicant operate any of the following? If so, please indicate location:
(a) Jail: Yes No
(b) Holding Cell: Yes No
(c) Detention Cell: Yes No
For each Facility indicate the following, if applicable. Use a separate sheet if necessary.
2. What is the state certified capacity of facility?
3. What is the average number of daily inmates?
4. What is the average length of stay?
5. Are there full-time jailers on duty twenty-four hours per day? Yes No
6. In the last five years, have there been any suicides or suicide attempts by inmates? Yes No
If “Yes”, explain incident, and provide details of preventative measures taken:
7. Are walk-throughs of the facility done every thirty minutes? Yes No
DISPATCHING
JAIL OR LOCK-UP FACILITIES
Page 6 of 11
8. Does Applicant have smoke detectors in the facility? Yes No
9. Does the Applicant have a procedures manual for the facility? Yes No
(a) Date of original procedures manual for facility:
(b) Date of last revision/update of manual:
10. Describe your suicide watch/surveillance procedures.
11. Are there audio/video systems in:
(a) Booking Area Audio Video
(b) Cell Area Audio Video
(c) Sally port/Intake area Audio Video
12. Are jail premises regularly inspected by:
(a) Department of Corrections Yes No Date of most recent inspection?
Recommendations Completed? Yes No
(b) County or State Fire Inspectors Yes No Date of most recent inspection?
Recommendations Completed? Yes No
(c) Department of Health Yes No Date of most recent inspection?
Recommendations Completed? Yes No
***ATTACH COPY OF INSPECTION REPORTS***
1. Provide your entity’s recent insurance history below.
Policy Period
Limits Per
Claim/Aggregate
Deductible
Annual
Premium
Occurrence or
Claims-Made
2. If you are currently insured for errors & omissions coverage on a claims-made policy, what is your policy’s
retroactive/prior acts date? (month/day/year)
/ / If there is no retroactive date, check here.
If requesting prior acts coverage you will be asked upon binding coverage to provide a copy of your current insurance
declaration page documenting the expiring retroactive date and limits. Prior acts coverage may not be available if
the date of your current retroactive coverage is different from what we have quoted or if there is any gap between
effective dates.
3. Are you being canceled or non-renewed by your current professional liability carrier? Yes No
If yes, please explain why:
4. Requested limits: $100k/$300k $250k/250k $500k/$500k $1M/$1M $2M/$2M
(other)
Requested deductible: $25,000 $50,000 $75,000 Other $
5. After inquiry with each person as appropriate including the applicant’s designated claim representative, in the last five
(5) years, have any law enforcement/police professional or personal injury claims been made against the entity
applying for insurance, or any of your past or present members, partners, officers, directors, employees, personnel or
any predecessors in business, whether the claim was insured or uninsured?
Yes No
INSURANCE AND LOSS HISTORY
Page 7 of 11
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include a currently valued
loss run for each claim.
6. After inquiry with each person as appropriate including the applicant’s designated claim representative, are you, or any
of your partners, officers, directors, employees or personnel aware of any circumstances, acts, errors, omissions, or any
allegations or contentions of any incident which may result in a law enforcement/police professional or personal injury
claim? Yes
No
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include a currently valued
loss run for each claim.
7. After inquiry with each person as appropriate including the applicant’s designated claim representative, have you, or
any of your partners, officers, directors, employees or personnel been the subject of any complaint or subject to any
disciplinary action by any state licensing agency or other regulatory body during the past five (5) years?
Yes No
If “yes”, please provide an explanation of the circumstances and penalty involved. If available, please provide a copy
of the complaint, your response, and a copy of the regulatory body’s decision.
Please provide currently valued Company Loss Runs for the past five (5) years summarizing your claim history.
FRAUD WARNING
NOTICE TO 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,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, 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 or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the 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
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: 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.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: 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 civil fines and criminal penalties.
Page 8 of 11
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
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 application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
click to sign
signature
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Page 9 of 11
LAW
ENFORCEMENT PROFESSIONAL LIABILITY SUPPLEMENTAL CLAIM APPLICATION
This form is to be completed when the Applicant has been involved in any claim or is aware of an incident which
may give rise to a claim. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT.
If space is insufficient to answer any questions fully, attach a separate sheet.
In lieu of attaching suit papers, please provide a complete narrative description of the allegations involved
1. Full Name of Applicant:
2. Full Name of Individual(s) or entity involved in the claim:
3. Additional defendants
4. Full Name of Claimant(s):
5. Indicate whether: CLAIM SUIT Incident/Circumstance Only (no claim or suit)
6. Date and location of alleged act, error or omission:
7. Date of claim: Date reported to Insurance Company:
8. What is the status of the claim? Closed/Settled Open/Pending Incident/Circumstance
9. IF CLOSED:
Total paid including deductible(s)? Responses such as “unknown” or “unavailable” are insufficient.
Defense costs
Loss/compensatory damages
Paid by you-out of pocket
$
$
Insurance Company
$
$
Date Resolved: / / Trial Out of Court
10. IF PENDING:
(a) Claimant’s settlement demand? $ Defendant’s settlement offer (if any): $
(b) Insurer’s reserve amounts? Loss $ Defense $
(c) Amounts already spent defending the claim? By you? $ By the insurer? $
(d) What is your best estimate of the likely settlement amount for this matter? $
(e) What is your best estimate of the date when you expect this claim to be resolved?
Note: Answering “unknown” or “unavailable” to the above questions is an insufficient response.
11. Name(s) of Insurer(s) responding to this claim or incident
Policy Number:
Limits of Liability: Deductible:
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 10 of 11
12. Provide narrative description of suit, claim or incident, including the allegations involved, the potential size of injury
and your response (do not attach suit papers):
13. Explain what action(s) have been taken to prevent reoccurrence of a similar claim including on what date such
measures were fully implemented:
14. Is the officer(s) or other employee(s) involved with the matter still employed by the Applicant? Yes No
If No, on what date did employment end?
I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my
Professional Liability Application. I understand that an incorrect or incomplete statement could void my protection.
Signature of Applicant/Title/Date (Must be signed by a Principal, Partner or Officer of the Firm)
FRAUD WARNING
NOTICE TO 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,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, 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 or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the 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
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: 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.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: 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 civil fines and criminal penalties.
Page 11 of 11
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
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 application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
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