Applicant/Named Insured: - Amazon S3



FORMCHECKBOX Acceptance Indemnity Insurance Company FORMCHECKBOX Occidental Fire & Casualty Company of North Carolina-127023745300 FORMCHECKBOX Acceptance Casualty Insurance Company FORMCHECKBOX Wilshire Insurance CompanyPlease answer ALL questions.Incomplete or missing answers may cause processing delays or decline of coverage.433768513525500232981513525500Requested policy period: Effective Date: FORMTEXT ????? Expiration Date: FORMTEXT ?????1.APPLICANT INFORMATION571320714784300a.Form of business: FORMCHECKBOX Individual FORMCHECKBOX Corporation FORMCHECKBOX Partnership FORMCHECKBOX Joint Venture FORMCHECKBOX Other: FORMTEXT ?????188214014478000b.Applicant/Named Insured: FORMTEXT ?????188595014922500(DBA): FORMTEXT ?????188595015557500c.Mailing Address: FORMTEXT ?????d.Garage Locations:Loc#AddressCityStateZipLot Protection1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMCHECKBOX Building FORMCHECKBOX Standard FORMCHECKBOX Nonstandard2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMCHECKBOX Building FORMCHECKBOX Standard FORMCHECKBOX Nonstandard3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMCHECKBOX Building FORMCHECKBOX Standard FORMCHECKBOX Nonstandard Building: Separate property supplemental application required.Standard Open Lot: Open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet height or bounded on one or more sides by the wall or walls of a building, with no unprotected openings, and with the exposed sides of lot enclosed by a metal cyclone or equivalent fence no less than six feet in height, with openings securely locked when unattended.e.Years in business: FORMTEXT ??Years experience in this industry: FORMTEXT ??Years ownership/management experience: FORMTEXT ??335100714455600f.Provide complete details of all prior work experience: FORMTEXT ?????32835851504950077216015240000g.Phone: FORMTEXT ?????Inspection Contact: FORMTEXT ?????134739515277400h.Website Address: FORMTEXT ?????288932515015900i.What are your days and hours of operation? FORMTEXT ?????239626613857900j.Describe your business operations? FORMTEXT ?????k.Are you engaged in any other operations? FORMCHECKBOX Yes FORMCHECKBOX No119947813783200If yes, explain: FORMTEXT ?????322998428313500l.Do you conduct operations or have driving exposures in any state(s) other than where your garage operation is domiciled? If yes, explain, including which state(s): FORMTEXT ?????2.PRIOR CARRIER / LOSS INFORMATIONa.During the past three (3) years, has any company ever cancelled, declined or refused to issue any similar insurance to the applicant? FORMCHECKBOX Yes FORMCHECKBOX No124878414829100If yes, explain: FORMTEXT ?????b.Prior carriers for the last three (3) years. If no prior insurance, state “NONE”.Carrier NamePolicy PeriodPremiumYear 1 FORMTEXT ????? FORMTEXT ?????to FORMTEXT ?????$ FORMTEXT ?????Year 2 FORMTEXT ????? FORMTEXT ?????to FORMTEXT ?????$ FORMTEXT ?????Year 3 FORMTEXT ????? FORMTEXT ?????to FORMTEXT ?????$ FORMTEXT ?????c.Prior loss information:Date of LossDescription of LossAmount PaidAmount Reserved FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????3.GENERAL UNDERWRITING INFORMATIONa.Do you loan, lease or rent vehicles to others? FORMCHECKBOX Yes FORMCHECKBOX Nob.Do you engage in any rideshare programs? FORMCHECKBOX Yes FORMCHECKBOX Noc.Do you own or sponsor a race car? FORMCHECKBOX Yes FORMCHECKBOX Nod.Do you repossess:(1)Autos that you have sold? FORMCHECKBOX Yes FORMCHECKBOX No(2)Autos for others? FORMCHECKBOX Yes FORMCHECKBOX Noe.Any salvage/auto dismantling operations? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, separate supplemental application required.f.Any animals kept on the premises? FORMCHECKBOX Yes FORMCHECKBOX No249487814605000If yes, what breed(s) and purpose?: FORMTEXT ?????g.Provide maximum radius for pickup and delivery:(1) FORMCHECKBOX Owned Autos: FORMTEXT ????? miles. 506326614119400(2) FORMCHECKBOX Non-Owned/Customer’s Autos: FORMTEXT ????? miles. How many times per month? FORMTEXT ?????497810114605000h.How many plates do you have: Dealer: FORMTEXT ????? Transport/Transit: FORMTEXT ????? Other: FORMTEXT ?????305517214119400(1)Where are plates stored when not in use? FORMTEXT ?????(2)Do you loan or rent plates? FORMCHECKBOX Yes FORMCHECKBOX Noi.Describe your key control procedures: 201974813697300(1)During business hours: FORMTEXT ????? 191665414108200(2)After business hours: FORMTEXT ?????j.Are firearms kept on the premises? FORMCHECKBOX Yes FORMCHECKBOX Nok.Do you utilize sub-contractors? FORMCHECKBOX Yes FORMCHECKBOX No277278413249100If yes:(1)Who and for what purpose?: FORMTEXT ?????(2)Are certificates of insurance obtained from all? FORMCHECKBOX Yes FORMCHECKBOX Nol.Do you attend or host trade shows, fairs, or any other special events? FORMCHECKBOX Yes FORMCHECKBOX No130705415004700If yes, explain: FORMTEXT ?????m.Percentage of operation (“X” all applicable operations below and show % of sales and/or % repair for each)Type of AutosSales %Repair % FORMCHECKBOX ATVs, Snowmobiles* FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Boats, Jet Skis or Other Watercraft FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Buses: Type: FORMTEXT ????? Passenger Capacity: FORMTEXT ??? FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Contractors/Construction Equipment* FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Emergency Vehicles: FORMCHECKBOX Police FORMCHECKBOX Fire FORMCHECKBOX Ambulance FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Farm Equipment FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Golf Carts FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Motorcycles, Scooters* FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Motor Homes, Recreational Vehicles, Campers* FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Private Passenger (including pickups, mini vans or SUVs) FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Trailers: FORMCHECKBOX Semi-Trailers FORMCHECKBOX Utility Trailers FORMCHECKBOX Fifth Wheels FORMCHECKBOX Livestock FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Trucks and/or Truck Tractors (other than pickups, mini vans or SUVs)* FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX Other (describe): FORMTEXT ????? FORMTEXT ???? FORMTEXT ????*Separate supplemental application required4.DEALER INFORMATION FORMCHECKBOX “X” if no dealer operations existsa.Are you a licensed dealer? FORMCHECKBOX Yes FORMCHECKBOX No 476294814268800113792014287500Dealer ID #: FORMTEXT ????? FORMCHECKBOX Non-Franchised FORMCHECKBOX Franchised with FORMTEXT ?????Type: FORMCHECKBOX Retail % FORMTEXT ??? FORMCHECKBOX Wholesale % FORMTEXT ??? FORMCHECKBOX Broker % FORMTEXT ??? FORMCHECKBOX Auction* % FORMTEXT ???*If Auction applies, separate supplemental application must be completed. b.Do you sell autos on consignment? (If yes, copy of agreement required) FORMCHECKBOX Yes FORMCHECKBOX NoIf yes: FORMCHECKBOX On your lot FORMCHECKBOX At other dealership locationsc.Estimate number of vehicles sold per year: FORMTEXT ?????d.Do you engage in Internet Sales? FORMCHECKBOX Yes FORMCHECKBOX No316274815127900If yes: (1) Who is responsible for title transfer? FORMTEXT ?????285346614866500(2) How are vehicles transported? FORMTEXT ?????e.Test drives: (1)Do you allow customers to test drive vehicles unaccompanied? FORMCHECKBOX Yes FORMCHECKBOX No(2)Do you obtain a copy of their Driver License? FORMCHECKBOX Yes FORMCHECKBOX No(3)Do you obtain a copy of their proof of insurance? FORMCHECKBOX Yes FORMCHECKBOX No(4)Do you allow overnight test drives? FORMCHECKBOX Yes FORMCHECKBOX Nof.Which of the following are used to transport or drive away vehicles from the places where they are purchased:462847813708500 FORMCHECKBOX Employees FORMCHECKBOX Contract Drivers FORMCHECKBOX Transport Carrier FORMCHECKBOX Other: FORMTEXT ?????g.Where do you purchase vehicles (provide %)?362891314306200 FORMCHECKBOX Other dealers FORMTEXT ??? FORMCHECKBOX Auction FORMTEXT ??? FORMCHECKBOX Other FORMTEXT ?????h.When are titles transferred? FORMCHECKBOX At time of sale FORMCHECKBOX When auto is paid in full102616014668500 FORMCHECKBOX Other: FORMTEXT ?????i.Do you require personal auto insurance to be in place prior to relinquishing a sold vehicle? FORMCHECKBOX Yes FORMCHECKBOX Noj.If you finance autos for sale (Buy-here/Pay-here operation), are you listed as a lienholder? FORMCHECKBOX Yes FORMCHECKBOX Nok.Value of owned (inventory) autosLoc#Average value per autoMaximum value per autoAverage # of autosMaximum # of autosMaximum value of all autos1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5.NON-DEALER INFORMATION FORMCHECKBOX “X” if no service/non-dealer operations existsMust equal 100%Service/RepairPercentage FORMCHECKBOX Airbags FORMTEXT ???? FORMCHECKBOX Alarm/Stereo Installation FORMTEXT ???? FORMCHECKBOX Auto PartsNew: FORMTEXT ???%Used: FORMTEXT ???%Uninstalled FORMTEXT ???% FORMTEXT ???? FORMCHECKBOX Body FORMTEXT ???? FORMCHECKBOX Brakes FORMTEXT ???? FORMCHECKBOX Breathalyzers/Ignition Interlock Devices FORMTEXT ???? FORMCHECKBOX Car Wash FORMCHECKBOX Attended FORMCHECKBOX Unattended/Self-Serve FORMTEXT ???? FORMCHECKBOX Detail Shop FORMTEXT ???? FORMCHECKBOX Drive-away contractors FORMTEXT ???? FORMCHECKBOX Engine FORMTEXT ???? FORMCHECKBOX Frame FORMCHECKBOX Cutting FORMCHECKBOX Welding FORMCHECKBOX Stretching FORMCHECKBOX Straightening FORMTEXT ???? FORMCHECKBOX Hydraulic FORMCHECKBOX Lifting apparatuses – Describe: FORMTEXT ????? FORMTEXT ???? FORMCHECKBOX LPG (Liquefied Petroleum Gas) FORMTEXT ???? FORMCHECKBOX Oil/Lube FORMTEXT ???? FORMCHECKBOX Painting FORMCHECKBOX U/L approved booth FORMCHECKBOX Non-U/L approved booth* FORMTEXT ???? FORMCHECKBOX Parking Facility: FORMCHECKBOX Public FORMCHECKBOX Valet** FORMTEXT ???? FORMCHECKBOX Performance Enhancements (Beyond original manufacturer specs) FORMTEXT ???? FORMCHECKBOX Service/Convenience Store** FORMCHECKBOX Gas FORMCHECKBOX Grocery FORMCHECKBOX Liquor FORMTEXT ???? FORMCHECKBOX Storage/Impound Lot FORMTEXT ???? FORMCHECKBOX Suspension FORMCHECKBOX Lift KitsHeight: FORMTEXT ????? FORMTEXT ???? FORMCHECKBOX Tires: FORMCHECKBOX New % FORMCHECKBOX Used % FORMCHECKBOX Recaps, Re-Treads, Split Rim Work FORMTEXT ???? FORMCHECKBOX Trailer Hitch Installation FORMCHECKBOX Bolt-On FORMCHECKBOX Weld-On FORMTEXT ???? FORMCHECKBOX Upholstery FORMTEXT ???? FORMCHECKBOX Windshield Installation/Tinting FORMTEXT ???? FORMCHECKBOX General Maintenance & Repair FORMTEXT ???? FORMCHECKBOX Other (describe): FORMTEXT ????? FORMTEXT ????**Separate supplemental application requiredWhere are operations performed? (provide % for each that apply) FORMCHECKBOX Your premises FORMTEXT ???? FORMCHECKBOX Customer Premises FORMTEXT ???? FORMCHECKBOX Roadside FORMTEXT ???? 96107314033500 FORMCHECKBOX Other: FORMTEXT ?????b.Do you modify, rebuild or perform conversions on vehicles? FORMCHECKBOX Yes FORMCHECKBOX No130397314351000If yes, explain: FORMTEXT ?????c.Do you weld? FORMCHECKBOX Yes FORMCHECKBOX No179451015144800(1)What do you weld? FORMTEXT ?????382270014319200(2)What protective safeguards are in place to prevent fire? FORMTEXT ?????d.Are signs posted to keep customers from work areas? FORMCHECKBOX Yes FORMCHECKBOX Noe.Do you manufacture or fabricate autos or auto parts? FORMCHECKBOX Yes FORMCHECKBOX No123981914631100If yes, explain: FORMTEXT ?????f.Do you offer expedited service (example: 30 min or less - quick lube)? FORMCHECKBOX Yes FORMCHECKBOX Nog.Value of non-owned (customer) autosLoc#Average value per autoMaximum value per autoAverage # of autosMaximum # of autosMaximum value of all autos1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6.OWNERS, EMPLOYEES AND DRIVERS INFORMATIONa.List all owners, employees, drivers and household members of driving age (ALL employees, whether they drive or not & ALL household members, whether involved in garage operations or not):First & Last NameDriver’s License Number / StateDOBAccidents & Violations (within the past 5 years)Status* (1–11)Hours Worked**Furnished (Personal use)Yes/NoPersonal Auto PolicyYes/NoExcluded DriverYes/No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDo you utilize unscheduled (contract) drivers? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes: 1.Do you verify each has a valid US driver’s license? FORMCHECKBOX Yes FORMCHECKBOX No2.How many times per month? FORMTEXT ??*Status:6Mechanic1Active Owner, Partner or Officer7Clerical2Inactive Owner, Partner or Officer8Scheduled Driver3Salesperson9Spouse of Owner, Partner or Officer4Manager10Child of Owner, Partner or Officer (whether licensed to drive or not)5Lot Person11Other: FORMTEXT ?????**Hours Worked:FFull Time (over 20 hours per week)PPart Time (20 hours or less per week)NNon-EmployeeHave all individuals with access to use a covered auto been listed on this application FORMCHECKBOX Yes FORMCHECKBOX No119947814900100If no, explain: FORMTEXT ????? 7.COVERAGE REQUESTEDProvide limits and deductibles for all requested coverages:COVERAGELIMITSDEDUCTIBLESGarage LiabilityEach Accident(Auto & Other Than Auto)Aggregate(Other Than Auto only)$ FORMTEXT ?????PD$ FORMTEXT ?????BI & PD$ FORMTEXT ????? FORMCHECKBOX 1x FORMCHECKBOX 2x FORMCHECKBOX 3xPersonal Injury Protection$ FORMTEXT ?????$ FORMTEXT ?????Uninsured MotoristsUnderinsured Motorists$ FORMTEXT ?????$ FORMTEXT ?????Medical Payments FORMCHECKBOX Auto & Premises FORMCHECKBOX Premises Only$ FORMTEXT ?????Errors & Omissions FORMCHECKBOX Odometer FORMCHECKBOX Truth in Lending FORMCHECKBOX TitleGaragekeepers FORMCHECKBOX Fire/Theft FORMCHECKBOX Specified Causes FORMCHECKBOX Comprehensive FORMCHECKBOX Legal FORMCHECKBOX Direct Excess FORMCHECKBOX Direct PrimaryPer LocationPer AutoLoc 1$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Loc 2$ FORMTEXT ?????Loc 3$ FORMTEXT ?????Dealers Physical Damage FORMCHECKBOX Fire/Theft FORMCHECKBOX Specified Causes FORMCHECKBOX ComprehensivePer LocationPer AutoLoc 1$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Loc 2$ FORMTEXT ?????Loc 3$ FORMTEXT ?????Loss Payee: FORMTEXT ?????False Pretense$ FORMTEXT ?????Broadened Coverage FORMCHECKBOX Personal Injury Liability FORMCHECKBOX Damage to Rented Premises$ FORMTEXT ?????Employment Practices$ FORMTEXT ?????$ FORMTEXT ?????Additional InsuredName: FORMTEXT ?????Address: FORMTEXT ?????Insurable Interest: FORMTEXT ????? FORMCHECKBOX Landlord FORMCHECKBOX Waiver of Subrogation FORMCHECKBOX Other: FORMTEXT ?????Optional Coverages not listed: FORMTEXT ?????Service vehicles, including tow trucks, car haulers and wreckers or specifically described autos:Are filings required? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list MC # and/or Certificate #: FORMTEXT ?????YearMakeModelVIN/Serial #MGVWUseRadiusIn-Tow1 FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Liability FORMCHECKBOX PIP FORMCHECKBOX UM/UIM FORMCHECKBOX Med Pay (Limits follow policy coverages) FORMCHECKBOX Physical Damage - Limit: $ FORMTEXT ????? Deductible: $ FORMTEXT ?????Loss Payee: FORMTEXT ?????2 FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Liability FORMCHECKBOX PIP FORMCHECKBOX UM/UIM FORMCHECKBOX Med Pay (Limits follow policy coverages) FORMCHECKBOX Physical Damage - Limit: $ FORMTEXT ????? Deductible: $ FORMTEXT ?????Loss Payee: FORMTEXT ?????3 FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Liability FORMCHECKBOX PIP FORMCHECKBOX UM/UIM FORMCHECKBOX Med Pay (Limits follow policy coverages) FORMCHECKBOX Physical Damage - Limit: $ FORMTEXT ????? Deductible: $ FORMTEXT ?????Loss Payee: FORMTEXT ?????The Applicant, Agent and/or Broker represents that the above statements and facts are true and that no material facts have been suppressed or pletion of this form does not bind coverage or commit the Company to policy issuance. NOTICE TO APPLICANTS (EXCEPT CO & NY):Any person who knowingly makes a claim containing false information or intentionally misrepresents any material fact or knowingly presents false or misleading information in an application for insurance may be guilty of a crime and subject to criminal and civil penalties.NOTICE TO COLORADO APPLICANTS: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 claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.NOTICE TO NEW YORK 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 insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. FORMTEXT ?????4981575153035002468880152400001333515299800 FORMTEXT ?????Applicant NameApplicant SignatureDate4981575146685002495550146685001333514664800 FORMTEXT ????? FORMTEXT ?????Producer NameProducer SignatureDate172212014922500014220300 FORMTEXT ????? FORMTEXT ?????Producer Phone Number Producer Street Address ................
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