To All Prospective Insureds: 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 and subjects such person to criminal and civil penalties in many states.
Notice to California Applicants: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state 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 and Louisiana 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 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 Oklahoma Applicants: 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. (Note: In Oklahoma the language must appear on the face of the
policy, or by endorsement or rider attached to the policy in 10 pt. font or larger).
Notice to Kansas Applicants: An act committed by 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.
Notice to Maine, Tennessee, Virginia and Washington Applications: 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/or denial of
insurance benefits.
Notice to Maryland Applicants: 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.
Notice to New Hampshire Applicants: Any person who, with a purpose to injure, defraud or deceive an 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.
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 $5,000 and the stated value of the claim for each such violation.
Notice to New York Applicants (Fire insurance applications): Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. The proposed insured affirms that the foregoing
information is true and agrees that these applications shall constitute a part of any policy issued whether attached or not and that any willful
concealment or misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy
Notice to New York Applicants (Automobile): Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another
to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of
motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not
to exceed $5,000 and the value of the subject motor vehicle or stated claim for each violation.”
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 purposes 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 Pennsylvania Applicants (Automobile): Any person who knowingly and with intent to injure or defraud any insurer files an application
or claim containing any false, incomplete or misleading information, shall, upon conviction, be subject to imprisonment for up to seven (7) years
and the payment of a fine of up to $15,000.
