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SUPPLEMENT FOR EMPLOYMENT RELATED SERVICES (Risk Placement Services, Inc.)

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MAST 1003 02 11 Page 1 of 2
SUPPLEMENT FOR EMPLOYMENT RELATED SERVICES
All questions MUST be completed in full.
If space is insufficient to answer any question fully, attach a separate sheet.
1. Applicant’s Name:
Location Address:
Mailing Address:
2. Is the Applicant properly lic
ensed where required by law? [ ] Yes [ ] No License Number
3. Number of active owners/officers/partners:
Number of Employees
4. Does the Applicant carry Workers’ Compensation cove
rage on temporary employees? ............................ [ ] Yes [ ] No
5. Does the Applicant subcontract work to others?............................................................................................ [ ] Yes [ ] No
If Yes, are certificates of insurance required?................................................................................................ [ ] Yes [ ] No
6. Do subcontractors name the Applicant as an additional insured? ................................................................ [ ] Yes [ ] No
7. Are reference/background checks required on all temporary employees?................................................... [ ] Yes [ ] No
8. Does the Applicant provide leased employees to others?............................................................................. [ ] Yes [ ] No
9. Is any assignment of temporary workers longer than six months? ............................................................... [ ] Yes [ ] No
10. Estimated annual: Payroll (excl. owner)
Receipts Subs
11. Provide payroll breakdown between:
Clerical
Non-clerical
Provide breakdown
of all Non-clerical operations.
Light
Industrial
(List Classes)
Payroll %
Heavy
Industrial
Payroll % Vehicle Operations Payroll %
Professional Payroll
%
Retail Payroll % Contracting Payroll %
12. If independent contractors are used, attach a copy of the independent contractor agreement.
13. Attach a copy of the client service agreement relating to staff placements.
Signing this Supplement does not bind the Company to provide or the Applicant to purchase the insurance.
It is understand that information submitted herein becomes a part of our application for insurance and is subject to the same
declarations, representations and conditions.
Must be signed by director, executive officer, partner or equivalent within 60 days of the proposed effective date.
Name of Applicant Title
Signature of Applicant Date
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MAST 1003 02 11 Page 2 of 2
Notice to Arkansas and West Virginia Applicants: 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.
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 policyholder 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.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance 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.
Notice to Maine Applicants: 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.
Notice to Maryland Applicants: Any person who knowingly and willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
Notice to New Mexico Applicants: 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.
Notice to New York Applicants: 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.
Notice to Ohio Applicants: 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.
Notice to Oklahoma Applicants: 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.
Notice to Oregon Applicants: Any person who, with intent
to defraud or knowing that he or she is facilita
ting a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Notice to Pennsylvania Applicants: 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.
Notice to Tennessee, Virginia and Washington Applicants: 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.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may
be guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other 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 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 civil penalties.
MAST 1004 02 11 Page 1 of 2
EXECUTIVE RECRUITING CONSULTANTS SUPPLEMENT
APPLICANT’S INSTRUCTIONS:
1. Answer all questions. If the answer requires detail, please attach a separate sheet.
2. Application must be signed and dated by owner, partner or officer.
3. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
(PLEASE TYPE OR PRINT IN INK)
1. APPLICANT INFORMATION
Name of Applicant:
2. APPLICANT RECRUITING OPERATIONS
Previous Last Estimate
Year
Year This Year
a. Breakdown of Total Staff
Professionals: __________ _________ __________
Other Employees: __________ _________ __________
Total: __________ _________ __________
b.
Number of Search Engagements: __________ _________
___________
c. Average salary level of completed placements: $_________ $_________ $__________
d. Highest salary level of completed placements: $_________ $_________ $__________
e. Describe in detail the percentage breakdown of the different industries with which your company renders
professional services (Total must equal 100%):
I understand information submitted herein becomes a part of my Application
and is subject to the same representation and
conditions.
Name of Applicant* Title (Officer, partner, etc.)
Signature of Applicant Date
One signed copy will be attached to the policy, cover note or certificate, if issued.
*Signing this form does not bind the applicant or the Company or the Underwriting Manager to complete the insurance.
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MAST 1004 02 11 Page 2 of 2
Notice to Arkansas and West Virginia Applicants: 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.
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 policyholder 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.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance 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.
Notice to Maine Applicants: 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.
Notice to Maryland Applicants: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may
be subject to fines and confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
Notice to New Mexico Applicants: 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.
Notice to New York Applicants: 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.
Notice to Ohio Applicants: 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.
Notice to Oklahoma Applicants: 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.
Notice to Oregon Applicants: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Notice to Pennsylvania Applicants: 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.
Notice to Tennessee, Virginia and Washington Applicants: I
t 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.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may be
guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other 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 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 civil penalties.
MAST 1000 02 11
Page 1 of 5
APPLICATION FOR SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY INSURANCE AND
SERVICE AND TECHNICAL PROFESSIONAL LIABILITY INSURANCE
(Claims Made Basis or Claims Made and Reported Basis)
If space is insufficient to answer any question fully, attach a separate sheet.
I. GENERAL INFORMATION
1. Full name of
Applicant:
2. Princi
pal business premise address:
(Street) (County)
(City) (State) (Zip)
3. Address(es) of Branch Office(s):
4. Web Site Add
ress(es):
5. Phone Number:
6. Numb
er of employees including principals: Full-time
Part-time Seasonal Total
7. Business is a: [ ] corporation [ ] partnership [ ] individual [ ] other
8. Date organi
zed (MM/DD/YYYY):
9. Is the Appli
cant controlled by, owned by, or commonly owned, affiliated or associated with any other organization?
................................................................................................................................................................... Yes [ ] No [ ]
If Yes, are any services provided to such organization(s)?....................................................................... Yes [ ] No [ ]
If Yes, to either of the above, provide details.
10. During the last year has the Applicant been involved in, or are they presently considering or contemplating:
(a) Any merger, consolidation or acquisition?....................................................................................... Yes [ ] No [ ]
If Yes, provide a complete explanation detailing liabilities assumed and any professional liability coverage
purchased by any predecessor organization.
(b) A change in the nature of busi
ness operations? ............................................................................. Yes [ ] No [ ]
If Yes, provide details.
11. Duri
ng the last year has the name of the Applicant been changed? ...................................................... Yes [ ] No [ ]
If Yes, provide details.
II. ADDITIONAL INFORMATION
1. If you are a new Applicant with this company, attach:
(a) A list of owners, partners and officers and percentage of ownership of each of the Applicant(s) named in Part I
Item 1. above.
(b) Latest annual financial statements (annual report or income statement and balance sheet). (Omit if gross
revenues are $500,000 or less.)
(c) Professional qualifications (i.e. resume or c.v.) of each of the owners, partners, officers and key employees of
the Applicant(s) named in Part I Item 1. above.
MAST 1000 02 11 Page 2 of 5
(d) Professional societies and organizations to which the Applicant and its owners, partners, officers and key
employees belong(s).
(e) Advertisements, brochures, and descriptive literature on the Applicant’s business.
(f) Sample contract for services between the Applicant and its clients.
(g) A list of and description of affiliations with any organization owned by any owner, partner or officer of any
Applicant.
2. If you are applying for renewal with this company, attach:
(a) A list of owners, partners and officers and percentage of ownership of each in the Applicant(s) named in Part I.
Item 1. above.
(b) Latest annual financial statements (annual report or income statement and balance sheet). (Omit if gross
revenues are $500,000 or less.)
(c) Any changes in any items provided last year pursuant to Items (c), (d), (e), (f) or (g) above.
III. PROFESSIONAL ACTIVITIES AND SPECIALTY
1. Describe all
professional services performed for others and indicate the percentage of gross revenues derived from
each activity.
Professional Services Percent of Gross Revenues
%
%
%
2. (a) Estimated annual gross revenues for the coming year: $
(b) Percentage of annual gross revenues for the coming year:
(i) Domestic:
%
(ii) Foreign:
%
(c) Annual gross revenues for the last three years:
(i) last twelve months: Year:
$
(ii) 1
st
prior year: Year: $
(iii) 2
nd
prior year: Year: $
3. Describe Applicant’s five largest jobs in the last three years:
Client Name Professional Services Gross Revenues
4. Is the Applicant engaged in any business or profession other than as described in Item 1 above? ........ Yes [ ] No [ ]
If Yes, explain.
5. Were more than 50% of the Applicant’s gross revenues for any of the last three years derived from any one contract?
................................................................................................................................................................... Yes [ ] No [ ]
If Yes, specify client, professional services and duration of contract.
6. Does the Applicant utilize the services of independent contractors or sub-consultants? ......................... Yes [ ] No [ ]
If Yes, indicate percentage of billings and whether a certificate of professional liability insurance is required of each.
MAST 1000 02 11 Page 3 of 5
7. (a) Does the Applicant, any of its subsidiaries and/or affiliates build, service, repair, install, manufacture or fabricate
anything?............................................................................................................................................. Yes [ ] No [ ]
(b) Does the Applicant, any of its subsidiaries and/or affiliates sell any product other than computer software?
............................................................................................................................................................ Yes [ ] No [ ]
If Yes, to either (a) or (b) describe.
8. Is any principal, partner, owner, officer, director, employee, manager or managing member of the Applicant a certified
public accountant, an attorney or lawyer, an architect or engineer, a provider of any form of healthcare services or
responsible for supervision or management of others who are providers of healthcare services? .......... Yes [ ] No [ ]
If Yes, advise of the name of the individual(s), their position(s) with the Applicant and the nature of services they
perform for clients of the Applicant.
IV. CLAIMS/HISTORY
1. During the last five years, have there been any claims or proceedings arising out of professional services against the
Applicant, or any of its principals, partners, owners, officers, directors, employees, managers, managing members, its
predecessors, subsidiaries, affiliates, and/or against any other person or organization proposed for this insurance?
................................................................................................................................................................... Yes [ ] No [ ]
If Yes, attach complete details including description of allegations, status of claim, amounts demanded or paid, date of
claim, and action taken to prevent the same type of claim in the future.
2. Is the Applicant or any principal, partner, owner, officer, director, employee, manager or managing member of the
Applicant or any person(s) or organization(s) proposed for this insurance aware of any fact, circumstance, situation,
incident or allegation of negligence or wrongdoing, which might afford grounds for any claim such as would fall under
the proposed insurance?........................................................................................................................... Yes [ ] No [ ]
If Yes, provide details.
3. Has any insurer cancelled, rescinded, nonrenewed or declined any similar insurance for the Applicant, its
predecessors, subsidiaries, affiliates and/or for any other person or organization proposed for this insurance in the last
five years? ................................................................................................................................................. Yes [ ] No [ ]
If Yes, attach a copy of such insurer’s notice. MISSOURI APPLICANTS – DO NOT ANSWER
4. Has the Applicant and/or any of its principals, partners, owners, officers, directors, managers and/or managing
members or employees, its predecessors, subsidiaries, affiliates, and/or any other person or organization proposed
for this insurance been involved in or have knowledge of any pending or completed investigative or administrative
proceedings or governmental regulatory proceedings, actions or notices?.............................................. Yes [ ] No [ ]
If Yes, provide details on a separate sheet.
5. Previous Professional Liability Insurance:
Policy
Period Insurer
Indicate whether
Claims Made or
Occurrence policy
Limits of Liability Deductible
Retro
Date
6. Does the Applicant carry General Liability Insurance?.............................................................................. Yes [ ] No [ ]
If Yes, provide: Insurer:
Limits:
Does coverage include Products/Completed Operations Hazards?......................................................... Yes [ ] No [ ]
MAST 1000 02 11 Page 4 of 5
NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY
No fact, circumstance or situation indicating the probability of a claim or action for which coverage may be afforded by the
proposed insurance is now known by any person(s) or entity(ies) proposed for this insurance other than that which is
disclosed in this application. It is agreed by all concerned that if there be knowledge of any such fact, circumstance or
situation, any claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.
The policy applied for is SOLELY AS STATED IN THE POLICY, if issued, which provides coverage on a claims made
basis for ONLY THOSE “CLAIMS” THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD,
unless the extended reporting period option is exercised in accordance with the terms of the policy. The policy has
specific provisions detailing claim reporting requirements.
The underwriting manager, Company and/or affiliates thereof are authorized to make any inquiry in connection with this
application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance.
This application, information submitted with this application and all previous applications and material changes thereto of
which the underwriting manager, Company and/or affiliates thereof receives notice is on file with the underwriting
manager, Company and/or affiliates thereof and is considered physically attached to and part of the policy if issued. The
underwriting manager, Company and/or affiliates thereof will have relied upon this application and all such attachments in
issuing the policy. If the information in this application or any attachment materially changes between the date this
application is signed and the effective date of the policy, the Applicant will promptly notify the underwriting manager,
Company and/or affiliates thereof, who may modify or withdraw any outstanding quotation or agreement to bind coverage.
WARRANTY
I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information
contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company
evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from
any prior insurer to the underwriting manager, Company and/or affiliates thereof.
Must be signed within 60 days of the proposed effective date.
Name of Applicant Title (Officer, partner, etc.)
Signature of Applicant Date
SPECIALTY SUPPLEMENT REQUIRED
ALTERNATE APPLICATION REQUIRED
Appraiser – Business or Property
Building/Home Inspector Association
Collection Agency Computer Related Other Than Consulting
Crane Inspector Environmental
Employment Related Services Franchisor
Escrow Only Trustees
Executive Recruiting Consultants
Freight Forwarder/Customs Broker
Insurance Related Services
Media Related Service
Mortgage Broker
Premium Finance
Real Estate Agent/Property Manager
Testing Lab
Third Party Administrator
Title, Escrow & Closing
Travel Related Services
Our Supplements and Applications are available at www.markelcorp.com
.
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MAST 1000 02 11 Page 5 of 5
Notice to Arkansas and West Virginia Applicants: 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.
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 policyholder 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.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance 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.
Notice to Maine Applicants: 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.
Notice to Maryland Applicants: Any person who knowingly and willfully presents a false or fraudulent claim for payment
of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
Notice to New Mexico Applicants: 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.
Notice to New York Applicants: 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.
Notice to Ohio Applicants: 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.
Notice to Oklahoma Applicants: 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.
Notice to Oregon Applicants: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of
insurance fraud.
Notice to Pennsylvania Applicants: 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 m
aterial thereto commits a f
raudulent insurance act, which
is a crime and subjects such person to criminal and civil penalties.
Notice to Tennessee, Virginia and Washington Applicants: 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.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance
may be guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other 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 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 civil penalties.
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SUPPLEMENT FOR EMPLOYMENT RELATED SERVICES (Risk Placement Services, Inc.)

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Completed 30 July 2020

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