Date:Pilot Signature:
Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and
VA, insurance benefits may also be denied)
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 of insurance, and civil damages. Any insurance company or agent of any 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
policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
In the District of Columbia, 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.
In Florida, any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony of the third degree.
In Hawaii, 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.
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, any application for the issuance of, or the rating of any
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.
In Massachusetts, Nebraska, Oregon and Vermont, any person who knowingly and with intent to defraud any insurance company or another 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,
may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.
In Minnesota, any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
In Ohio, 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
deception statement is guilty of insurance fraud.
In Oklahoma, WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy
containing any false, incomplete or misleading information is guilty of a felony.
In 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 include imprisonment, fines, and denial of insurance benefits.
As a normal part of the Company's underwriting procedure a routine inquiry may be made which will include information concerning general information, personal
characteristics and mode of living.
In the United States Public Law 91-308 (Federal Fair Credit Reporting Act) requires that if such a report is made upon your written request within a reasonable time after
you receive this notice, additional information as the nature and scope of the inquiry will be provided.
You have my consent to contact pilot training facilities which I have attended for information relating to my training and I hereby expressly authorize any such pilot
training facilities to release information about me.
I certify that the statements in this form are true to the best of my knowledge and belief, and I have not knowingly or intentionally concealed any pertinent information.
FRAUD WARNINGS
Have you ever had an aircraft claim, incident or accident?
Yes No
Has your pilot certificate ever been suspended or revoked?
NoYes
Yes No
Have you ever been investigated, cited or fined for violation of an aviation regulation?
Explain each 'Yes' answer fully:
Have you ever been convicted of a felony or are you under indictment for a felony?
Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or of reckless driving?
Has your driver's license ever been suspended or revoked?
Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics?
Has your pilot certificate ever been suspended or revoked?
NoYes
NoYes
Yes No
NoYes
Yes No
Answer all questions:
Pilot Name:
Page 2 of 2UWPHF (06-12)
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