Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or
fraudulent claim for payment of a loss or benefit or 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. *Applies in MD only.
Applicable in CO: 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.
Applicable in FL and OK: 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)*. * Applies in FL only.
Applicable in KS: 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, 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.
Applicable in KY, NY, OH and PA: 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 (not to exceed five thousand dollars and the
stated value of the claim for each such violation)*. *Applies in NY only.
Applicable in ME, TN, VA, and WA: 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 and denial
of insurance benefits. *Applies in ME only.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy
is subject to criminal and civil penalties.
Applicable in OR: 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 PR: 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.
Applicable in 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 material fact, commits a fraudulent
insurance act, which is a crime and may also be subject to civil penalty.
I/We understand that this is an application for insurance only and that the completion and submission of this
Application does not bind the Company to sell nor the applicant to purchase this insurance. I/We hereby declare
that the above statements and particulars are true and I/we agree that this Application shall be the basis for any
contract of insurance issued by the Company in response to it.
Electronic Signature of Applicant or Authorized Representative:
Title: Date:
If you prefer not to return the questionnaire with an electronic signature, please print and sign.
220APP0220 Page 5 of 5
click to sign
signature
click to edit