Insurance Fraud Warning Any person who knowingly, and with intent to defraud or deceive 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 in certain jurisdictions and is a felony in some states. Such persons may be subject to criminal and civil penalties including fines, imprisonment, and denial of insurance. (Not applicable in Pennsylvania. For the Insurance Fraud Warning in Pennsylvania, refer to the information below.)
Applicable in Colorado only: The following additional statement applies. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy 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 New York only: Any person who commits a fraudulent insurance act as described above shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Applicable to Pennsylvania only: 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.
Acknowledgments
The undersigned declares that to the best of his or her knowledge, the statements set forth herein are true and correct and that reasonable efforts have been made to obtain sufficient information from each and every proposed Insured to facilitate the proper and accurate completion of this Application. The signing of the Application does not bind the insurance company to complete the insurance, but it is agreed that this Application and any additional documents submitted therewith are the representations of the Insured and are material and shall be the basis of the contract should a policy be issued. It is further agreed that any incorrect or incomplete statement in the Application could void the protection should a policy be issued.
The undersigned further agrees that if any significant adverse change in the condition of the Applicant is discovered between the date of completion of this Application and the date that coverage was bound with the Insuring Company, and such change renders this Application inaccurate or incomplete, notice of such change will be reported in writing to Promont Advisors LLC immediately.
This Application shall be considered attached to and part of the Policy. Any material submitted with the Application shall be maintained on file with the Insurer and shall be deemed to be attached hereto as if physically attached.