NOTICE TO OREGON APPLICANTS ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD

Notice to oregon applicants any person who knowingly

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NOTICE TO OREGON APPLICANTS: 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO PENNSYLVANIA APPLICANTS: 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 103536 (6/16)
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Financial Lines Crisis Management CrisiSolution Insurance Application 5 of 5 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. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: 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. NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW. NOTICE: THIS APPLICATION IS FOR THE PURPOSE OF OBTAINING A QUOTATION AND DOES NOT BIND THE APPLICANT OR THE COMPANY TO COMPLETE THE INSURANCE. HOWEVER, IF A POLICY IS LATER ISSUED, THIS FORM SHALL BE THE BASIS OF AND BECOME PART OF THE CONTRACT. THE UNDERSIGNED APPLICANT WARRANTS THAT TO THE BEST OF HIS OR HER KNOWLEDGE THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE APPLICANT FURTHER WARRANTS THAT IF THE INFORMATION SUPPLIED ON THE APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME WHEN THE POLICY IS ISSUED, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY IN WRITING OF ANY CHANGE, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENTS TO BIND THE INSURANCE. AUTHORIZED SIGNATURE: NAME AND TITLE OF AUTHORIZED OFFICER: DATE: PLEASE RETURN BY MAIL TO: OR FAX TO: Financial Lines (214) 758-8845 Crisis Management 600 North Pearl St., 4 th Floor Dallas, TX 75201 103536 (6/16)
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