PDO-1100W-IND Ed. 01-09 Printed in U.S.A. Page 5 of 6
© 2009 The Travelers Companies, Inc. All Rights Reserved
X. FRAUD WARNINGS
Attention: Insureds in Alabama, Arkansas, D.C., Maryland, New Mexico, and Rhode Island
Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may
be subject to fines and confinement in prison.
Attention: Insureds 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 from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Attention: Insureds 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.
Attention: Insureds in Kentucky, New Jersey, New York, Ohio, and 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. (In New York, the civil penalty is not to exceed five thousand dollars
($5,000) and the stated value of the claim for each such violation.)
Attention: Insureds in Louisiana, Maine, Tennessee, Virginia, 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 include imprisonment, fines, and denial of insurance benefits.
Attention: Insureds in Oregon
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 may be guilty of a crime and may be subject to fines and
confinement in prison.
Attention: Insureds 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 with the penalty of 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.
XI. SIGNATURE SECTION
THE UNDERSIGNED AUTHORIZED REPRESENTATIVE (PRESIDENT, CEO, OR OTHER OFFICER ACCEPTABLE
TO TRAVELERS) OF THE APPLICANT DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,
AFTER REASONABLE INQUIRY, THE STATEMENTS SET FORTH IN THE ATTACHED TRAVELERS NEW
BUSINESS OR RENEWAL APPLICATION FOR INSURANCE ARE TRUE AND COMPLETE AND MAY BE RELIED
UPON BY TRAVELERS. IF THE INFORMATION IN ANY APPLICATION CHANGES PRIOR TO THE INCEPTION
DATE OF THE POLICY, THE APPLICANT WILL NOTIFY THE COMPANY OF SUCH CHANGES, AND THE
COMPANY MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION. THE COMPANY IS AUTHORIZED TO
MAKE INQUIRY IN CONNECTION WITH THIS APPLICATION.
THE SIGNING OF THIS APPLICATION DOES NOT BIND THE COMPANY TO OFFER, NOR THE APPLICANT TO
PURCHASE, THE INSURANCE. IT IS AGREED THAT THIS APPLICATION, INCLUDING ANY MATERIAL
SUBMITTED THEREWITH, SHALL BE THE BASIS OF THE INSURANCE AND SHALL BE, IN ALL STATES OTHER
THAN NC AND UT, CONSIDERED PHYSICALLY ATTACHED TO AND PART OF THE POLICY, IF ISSUED. THE
COMPANY WILL HAVE RELIED UPON THIS APPLICATION, INCLUDING ANY MATERIAL SUBMITTED
THEREWITH, IN ISSUING THE POLICY.