Fillable Insurance Application Form (Page 3 of 3) in pdf

Notice to Insured:

Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and civil penalties

[NY: not to exceed five thousand dollars and the stated value of the claim for each such violation] (Not applicable in CO, HI, NE, OH,

OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied).

Colorado

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.

New Jersey

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil

penalties.

Ohio

Any person who, with intent to defraud or knowing that he/she 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

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.

• • • • •

I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the

information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the

best of my knowledge, all information provided is complete, true and correct.

I also understand that no insurance will be in effect unless and until the insurance company, or Floodwatch as its agent, provides a

quotation offering to provide insurance coverage and the insurance company, or Floodwatch as its agent, receives written notice that

the terms and conditions contained in the insurance quotation provided are accepted.

Signature of applicant (insured):_______________________________________Date:______________________

FLOODWATCH 4 WEST MAIN ST STE 600

SPRINGFIELD OH 45502

P. 800.833.5912

F. 937.323.0787

EMail:

XS Flood App Rev 4/09

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Insurance Application Form Page 3