CIVIL UNION (if applicable)
MARITAL STATUS /
FEIN (if applicable)
CIVIL UNION (if applicable)
MARITAL STATUS /
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME OF INSURED (First, Middle, Last) INSURED'S MAILING ADDRESS
FEIN (if applicable)DATE OF BIRTH
INSURED
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME OF SPOUSE (First, Middle, Last) (if applicable) SPOUSE'S MAILING ADDRESS (if applicable)
DATE OF BIRTH
FAX
(A/C, No):
AGENCY
NAME:
CONTACT
(A/C, No, Ext):
PHONE
SUBCODE:CODE:
AGENCY CUSTOMER ID:
ADDRESS:
E-MAIL
DESCRIBE LOCATION OF LOSS IF NOT AT SPECIFIC STREET ADDRESS:
REPORTED BY
REPORTED TO
REPORT NUMBER
LOSS
POLICE OR FIRE DEPARTMENT CONTACTED
COUNTRY:
CITY, STATE, ZIP:
STREET:
LOCATION OF LOSS
PROBABLE AMOUNT ENTIRE LOSS
KIND OF
LOSS
WIND
FLOOD
HAIL
LIGHTNING
THEFT
FIRE
DESCRIPTION OF LOSS & DAMAGE (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
NAIC CODECARRIER
POLICY NUMBER
FLOOD POLICY
NAIC CODECARRIER
POLICY NUMBER
WIND POLICY
NAIC CODECARRIER
POLICY NUMBER
INSURED LOCATION CODE DATE OF LOSS AND TIME
AM
PM
PROPERTY / HOME POLICY
PROPERTY LOSS NOTICE
DATE (MM/DD/YYYY)
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME OF CONTACT (First, Middle, Last) CONTACT'S MAILING ADDRESS
CONTACT CONTACT INSURED
WHEN TO CONTACT
© 1988-2016 ACORD CORPORATION. All rights reserved.Page 1 of 3
The ACORD name and logo are registered marks of ACORD
LINE OF BUSINESS
ACORD 1 (2016/10)
ACORDs provided by Forms Boss. www.FormsBoss.com; (c) Impressive Publishing 800-208-1977
Applicable in Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in
prison, or any combination thereof.
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AGENCY CUSTOMER ID:
Page 2 of 3
Applicable in Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
containing false, incomplete, or misleading information may be prosecuted under state law.
Applicable in Arizona: For your protection Arizona law requires the following statement to appear on
this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
Applicable in Arkansas: 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.
Applicable in California: For your protection California law requires the following to appear on this form. Any person who knowingly
presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state
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 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 for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
Applicable in Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony.
Applicable 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.
Applicable in Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Applicable in Hawaii: Any person who intentionally or knowingly misrepresents or conceals material facts, opinions, intention, or law to
obtain or attempt to obtain coverage, benefits, recovery, or compensation commits the offense of insurance fraud which is a crime
punishable by fines or imprisonment or both.
Applicable in Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement
containing any false, incomplete or misleading information is guilty of a felony.
Applicable in Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,
incomplete, or misleading information commits a felony.
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, electronic,
electronic impulse, facsimile, magnetic, oral, or telephonic communication or 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.
ACORD 1 (2016/10)
Applicable in Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a 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.
AGENCY CUSTOMER ID:
Page 3 of 3
Applicable in Louisiana: 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.
Applicable in 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, fines or denial of insurance benefits.
Applicable in Michigan: 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.
Applicable in Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Applicable in Nevada: Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any
false, incomplete or misleading information concerning a material fact is guilty of a category D felony.
Applicable in Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
Applicable in New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement
of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as
provided in RSA 638:20.
Applicable in New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject
to criminal and civil penalties.
Applicable in New Mexico: 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.
Applicable in 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.
Applicable in Ohio: Any person who, with intent to defraud or knowing that he 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.
Applicable 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.
Applicable in Pennsylvania: 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.
Applicable in Rhode Island: 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.
Applicable in Tennessee: 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.
Applicable in Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and
may be subject to fines and confinement in state prison.
Applicable in Virginia: 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.
Applicable 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.
Applicable in West Virginia: 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.
ACORD 1 (2016/10)
Applicable in Oregon: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an
application containing a false statement as to any material fact may be violating state law.
Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance
application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents
more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a
fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for
three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a
maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
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