Liability Application For Pest Control Program (Page 4 of 4) in pdf

NOTICE: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY

OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING

INFORMATION MAY BE GUILTY OF INSURANCE FRAUD.

Any person who knowingly presents a false or fraudulent claim for

NOTICE TO ARKANSAS, LOUISIANA AND NEW MEXICO APPLICANTS:

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.

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an

NOTICE TO COLORADO APPLICANTS:

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.

Warning: It is a crime to provide false or misleading information to an insurer for the

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:

purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny

insurance benefits if false information materially related to a claim was provided by the applicant.

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of

NOTICE TO FLORIDA APPLICANTS:

claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third degree.

Any person who knowingly and with the intent to defraud any Insurance Company or other person files

NOTICE TO KENTUCKY APPLICANTS:

an application for insurance 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.

It is a crime to provide false, incomplete or misleading information to an Insurance Company for the

NOTICE TO MAINE APPLICANTS:

purpose of defrauding the Company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Any person who includes any false or misleading information on an application for an insurance

NOTICE TO NEW JERSEY APPLICANTS:

policy is subject to criminal and civil penalties.

Any person who knowingly and with intent to defraud any insurance company or other person files an

NOTICE TO NEW YORK APPLICANTS:

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.

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits

NOTICE TO OHIO APPLICANTS:

an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,

NOTICE TO OKLAHOMA APPLICANTS:

makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Any person who knowingly and with the intent to defraud any Insurance Company or other person

NOTICE TO PENNSYLVANIA APPLICANTS:

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.

Any person who knowingly and with the intent to defraud, presents false information in an

NOTICE TO PUERTO RICO APPLICANTS:

insurance request form, or who presents, helps, or has presented a fraudulent claim for the payment of a loss or other benefit, or presents

more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of

no less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3)

years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five

(5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.

It is a crime to knowingly provide false, incomplete or misleading

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS:

information to an Insurance Company for the purpose of defrauding the Company. Penalties include imprisonment, fines and denial of

insurance benefits.

NOTE: THIS APPLICATION MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN OR CEO OF THE APPLICANT ACTING AS THE

AUTHORIZED AGENT OF THE PERSON(S) AND ENTITY(IES) PROPOSED FOR THIS INSURANCE.

___________________________________ _________________________________

_______________

APPLICANT’S SIGNATURE

TITLE

DATE

BROKER’S COMPANY

BROKER NAME

WEBSITE

ADDRESS

CITY

STATE

ZIP

TELEPHONE

FAX

Liability Application For Pest Control Program Page 4

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