Specified Professions Professional Liability Application Form (Page 4 of 4) in pdf

Colorado Fraud Statement: 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 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.

District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the 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.

Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

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

Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files 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.

Maine and Washington Fraud Statement: 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 or a denial of insurance benefits.

New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is

subject to criminal and civil penalties.

New York Fraud Statement: 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.

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

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

Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim

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

Pennsylvania Fraud Statement: 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.

Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance

company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Fraud Statement (All Other States): 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.

Broker’s Signature ____________________________________________________________________________________________________________

Some states require that we have the Name and Address of your (Applicant’s) Authorized Agent or Broker.

Name of Authorized Agent or Broker ____________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________________

Mail complete application through local Agent or Broker to: ________________________________________________________________________

____________________________________________________________________________________________________________________________

Applicant’s Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and statements set

forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The

undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may

render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the applied for which may render

inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw

or modify and outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does not bind the

undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is understood the

Company is relying on the Application in the event th Policy is issued. It is agreed that this Application, including any material submitted

therewith, shall be the basis of the contract should a policy be issued, and may be attached to and become part of the policy.

Applicant’s Signature ____________________________________________ Title __________________________ Date ________________________

(Principal, Officer or Partner)

Professional

CONSA 1/08 - United States Liability Insurance Group

page 4 of 4

Specified Professions Professional Liability Application Form Page 4

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