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5. After inquiry with each person as appropriate, during the last 12 months, have any claims Yes No
been made against the person or entity applying for insurance, or any of your past or
present members, partners, officers, directors, employees, or any predecessors in business?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
6. After inquiry with each person as appropriate, have any new claims/incidents/circumstances Yes No
been reported to any previous carrier including under an extended reporting period?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
7. Please provide details of any status changes in previously reported claims including changes in
amounts paid in defense costs or to settle claims.
Please include an updated loss run for any previously reported unresolved claims.
8. After inquiry with each person as appropriate, are you, or any of your partners, officers, Yes No
directors, or employees, aware of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident which may result in a claim?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
9. After inquiry with each person as appropriate, have you, or any of your partners, officers, directors, Yes No
or employees been the subject of any complaint or subject to any disciplinary action by any state
licensing agency or other regulatory body during the last 12 months?
If “yes”, please provide an explanation of the circumstances and penalty involved. If available,
please provide a copy of the complaint, your response, and a copy of the regulatory body’s decision.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: 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.
INSURANCE AND LOSS HISTORY
