IMPORTANT NOTICE TO POLICYHOLDER
"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."
As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension of the insurance to which this application is made. The applicant, upon written request, will be informed whetheror not a consumer report was requested - and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report. The person completing this survey hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.