APPL-BANC-PPL-01 0413 Page 4 of 5
Fraud Warning
Representation Statement
The undersigned declare that, to the best of their knowledge and belief, the statements in this Application, any prior Applications, any additional material submitted, and any publicly
available information published or led by or with a recognized source, agency or institution regarding business information for the Applicant for the 3 years prior to the Bond/
Policy’s inception [hereinafter called “Application”] are true, accurate and complete, and that reasonable efforts have been made to obtain sufcient information from each and every
individual or entity proposed for this insurance. It is further agreed by the Applicant that the statements in this Application are their representations, they are material and that the
Bond/Policy is issued in reliance upon the truth of such representations.
The signing of this Application does not bind the undersigned to purchase the insurance and accepting this Application does not bind the Insurer to complete the insurance or
to issue any particular Bond/Policy. If a Bond/Policy is issued, it is understood and agreed that the Insurer relied upon this Application in issuing each such Bond/Policy and any
Endorsements thereto. The undersigned further agrees that if the statements in this Application change before the effective date of any proposed Bond/Policy, which would render
this Application inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately.
New Applicants:
It is understood and agreed that any claim arising from any prior or pending litigation or written or oral demand shall be excluded from
coverage. It is further understood and agreed that if any fact, circumstance or situation which could reasonably be expected to give
rise to a future claim exists, any claim or action subsequently arising therefrom shall also be excluded from coverage.
Renewal Applicants:
It is understood and agreed that if the undersigned or any insured has knowledge of any fact, circumstance or situation which could
reasonably be expected to give rise to a future claim, then any increased limit of liability or coverage enhancement shall not apply to
such fact, circumstance, or situation. In addition, any increased limit of liability or coverage enhancement shall not apply to any claim,
fact, circumstance or situation for which the Insurer has already received notice.
Any person who knowingly and with intent to defraud any insurance company or another person les 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 may be a crime and may subject the
person to criminal penalties.
ALABAMA, ARKANSAS, LOUISIANA, NEW JERSEY, NEW MEXICO, RHODE ISLAND, VIRGINIA and WEST VIRGINIA: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly presents false information in an Application for insurance is guilty of a crime. In Alabama, Arkansas, Louisiana, Rhode
Island and West Virginia that person may be subject to nes, imprisonment or both. In New Mexico, that person may be subject to civil nes and criminal penalties. In Virginia, penalties
may include imprisonment, nes and denial of insurance benets.
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, nes, 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.
DISTRICT OF COLUMBIA, KENTUCKY and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person les an Application
for insurance or statement of claim containing 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. In District of Columbia, penalties include imprisonment and/or nes. In addition, the Insurer may deny insurance benets if the Applicant
provides false information materially related to a claim. In Pennsylvania, the person may also be subject to criminal and civil penalties.
FLORIDA and OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive the Insurer, les a statement of claim or an Application containing any false,
incomplete or misleading information is guilty of a felony. In Florida it is a felony to the third degree.
KANSAS: An act committed by 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 benet pursuant to an insurance policy for personal or commercial 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 is considered a crime.
MAINE: 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, nes or denial of insurance benets.
MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benet or knowingly or willfully presents false information in an
Application for insurance is guilty of a crime and may be subject to nes and connement in prison.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against the Insurer, submits an Application or les a claim containing a false or deceptive
statement is guilty of insurance fraud.
OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to nes and connement in prison.
TENNESSEE 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, nes and/or denial of insurance benets.