MH-APP (3-07) Page 3 of 3
24. Any bankruptcy or foreclosure proceedings filed? ...................................................................................... Yes No
Reason:
Discharged?................................................................................................................................................. Yes No
Date of discharge:
25. Has the applicant ever been charged with arson or fraud?......................................................................... Yes No
26. Any losses at this location or any other location owned/rented within the last three years? ..................... Yes No
If yes, please describe:
Date Description Amount
PRIVACY POLICY: I have received and read a copy of the “National Casualty Company Privacy Statement and Proce-
dures.” By submitting this application, I am applying for issuance of a policy of insurance and, at its expiration, for appro-
priate renewal policies issued by National Casualty Company and/or other members of the Scottsdale group of insurance
companies. I understand and agree that any information about me that is contained in, or that is obtained in connection
with this application or any policy issued to me may be used by any company within the Scottsdale group to issue, review,
and renew the insurance for which I am applying.
FAIR CREDIT REPORTING ACT NOTICE: This notice is given to comply with Federal Fair Credit Reporting Act (Public
law 91-508) and any similar state law which is applicable as part of our underwriting procedure. A routine inquiry may be
made which will provide information concerning character, general reputation, personal characteristics and mode of living.
Upon written request, additional information as to nature and scope of the report will be provided.
FRAUD WARNING: 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 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.
FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON): It is a crime to knowingly provide false, in-
complete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK: 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 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 five thousand dollars
and the stated value of the claim for each such violation.
APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT’S AND PRODUCER’S SIGNATURES.
Applicant’s Signature:
__________________________________________________________ Date:
Producer’s Signature: __________________________________________________________ Date:
Agent Name: Agent License No.:
(Applicable to Florida Agents Only)
Iowa Licensed Agent:
(Applicable in Iowa Only)
