Fillable Haunted Trails & Hayrides Insurance (Page 5 of 5) in pdf

FRAUD STATEMENTS

Cossio Insurance Agency

864-688-0121

Fax: 864-603-2348

P.O. Box 5987, Greenville, SC 29606



FRAUD NOTICE

GENERAL STATEMENT: 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 [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA,

insurance benefits may also be denied)

APPLICABLE IN 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or

claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance

within the Department of Regulatory Agencies.

APPLICABLE IN THE DISTRICT OF COLUMBIA: 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.

APPLICABLE IN FLORDIA: 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.

APPLICABLE IN HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a

loss or benefit is a crime punishable by fines or imprisonment, or both.

APPLICABLE IN KANSAS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with

knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as

part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a

claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to

contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning

any fact material thereto commits a fraudulent insurance act.

APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT: 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, may be committing a fraudulent insurance act,

which may be a crime and may subject the person to criminal and civil penalties.

APPLICABLE IN MINNESOTA: Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a

crime.

APPLICABLE IN 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 deception statement is guilty of insurance fraud.

APPLICABLE IN 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.

APPLICABLE IN WASHINGTON: 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.

I understand that the insurance company, in determining in whether to provide insurance coverage, will

rely on the information contained in this form and all other information submitted. I hereby warrant,

represent and confirm that, to the best of my knowledge, all information provided is complete, true and

correct.

Insured Signature:

Date:

Haunted Trails & Hayrides Insurance Page 5

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