Pedicab Business Insurance Affirmation - Nyc Department Of Consumer Affairs (Page 2 of 2) in pdf

Pedicab Business Insurance Affirmation - Nyc Department Of Consumer Affairs Page 2

_______ I understand that I must notify the Special Application Unit of the Department of

Consumer Affairs at 42 Broadway, New York, NY 10004, if my insurance policy is cancelled,

amended, modified, or substituted, within fourteen days of notice from my insurance provider. I

understand that failure to provide this notification may result in seizure of my pedicab(s),

revocation of my license, and fines.

AFFIRMATION

I affirm that I am authorized to complete and submit this affirmation. I also affirm that I have

personally reviewed all of the information entered in this affirmation and it is true, correct, and

complete to the best of my knowledge.

PENALTY FOR FALSE STATEMENTS: It is against the law to make a statement in this

document that you know is false. If you make a statement that you know is false, you may be

punished.

Under Sections 210.45 and 175.30 of the New York Penal Law, you may be:

▪

fined up to $1,000 and / or

▪

sent to jail for up to one year

Under Section 175.35 of the New York Penal Law, you may be punished if you:

▪

make a statement that you know is false and / or

▪

make the statement because you intend to mislead the Department of Consumer Affairs

Under Section 175.35 of the New York Penal Law, you may be:

▪

fined up to $5,000 or

▪

fined an amount that is twice the amount of money you received by making the false

statement and / or

▪

sent to jail for up to 4 years

The Department of Consumer Affairs may also punish you for making a false statement on this

Application. These punishments may include:

▪

fines or penalties of up to $500 for each false statement

▪

permanent loss (revocation) of your license

__________________________________________

_________________________

Signature

Date

Pedicab Business Insurance Affirmation - Nyc Department Of Consumer Affairs Page 2