Sole Proprietor And Group Of One Attestation Form Page 2

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Sole Proprietor and Group of One
Attestation Form
The undersigned certifies that, to the best of his or her knowledge and belief, and under penalty of perjury, the information listed above is
true and complete.
X.
Signature of Applicant
Date
Oxford insurance products are underwritten by Oxford Health Insurance, Inc.
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 violation.
NY-07-134
9503

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