Section A: Applicant Information
Section B: Prior/Current Insurance Information
Section C: Insurance Limits (General Liability)
Section D: Underwriting Information
Number of Employees (Excluding Owner)
Number of Certifications (Both Owner and Employees)
Estimated Payroll for the next 12 Months (Excluding Owner)
Breakdown Type of Work Done by Percentage:
Breakdown of Product Sales by Product Type:
Breakdown of Work Done by Percentage
Section E: Subcontracted Work
Section F: Retail Operations
Section G: Property Insurance
Section H: Residential/Commercial Operations
Section I: Claims History for the Last 5 Years
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 and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may
be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated
value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and
Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to
fines or confinement in prison.
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 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.
Applicable in Florida and Oklahoma: 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 (In FL, a person is guilty of a felony of the third degree).
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 Maine, Tennessee, Virginia and 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 may include imprisonment, fines or a denial of insurance benefits.
Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or
presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the
same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars
($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating
circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may
be reduced to a minimum of two (2) years.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN
MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT
AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
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